Refer to: Lim RC: Abdominal vascular injuries (Trauma Rounds). West J Med 123:321-324, Oct 1975
Trauma oun
s
Chief Discussant ROBERT C. LIM, MD
Editors DONALD D. TRUNKEY, MD F. WILLIAM BLAISDELL, MD
Abdominal Vascular Injuries
This is one of a series of Conferences on Trauma at San Francisco General Hospital
WILLIAM COPELAND, MD: * The patient is a 16year-old Latin American girl who was admitted with a self-inflicted gunshot wound of the right epigastrium. The exit wound was above the left iliac crest posteriorly. When first evaluated in the emergency room, blood pressure was 130/80 mm of mercury and pulse was 110 and regular. However, peripheral perfusion was decreased as shown by cool, pale extremities. Sensorium was intact. No abnormalities were noted on initial urinalysis and the urine was found to be without red cells. After placement of a large-bore cutdown and rapid infusion of Ringer's lactate solution, the patient was moved to the x-ray department so that films of the chest and abdomen could be made. The film of the chest showed no abnormalities. During the radiological examination an expanding mass in the left lower quadrant was noted and films of the abdomen confirmed this. Immediate exploration of the abdomen showed the following injuries (1) a through and through laceration of the right gastroepiploic artery and vein, (2) a through and through wound of the third portion of the duodenum, (3) a wound of the infrarenal aorta approximately 1 cm in size with extensive retroperitoneal bleeding. The bul*Intern, Trauma Service, San Francisco General Hospital. Sponsored by the American College of Surgeons Northern California Trauma Committee. Supported in part by NIH Grant GM18470. Reprint requests to: Donald D. Trunkey, MD, Department of Surgery, San Francisco General Hospital, San Francisco CA 94110.
let exited through the left psoas muscle, lacerating a lumbar artery. Proximal and distal control of the aortic injury was obtained and the laceration was sutured with running 4-0 vascular suture. The gastroepiploic artery was ligated and the duodenal wounds were closed with a double layer technique. The duodenum was decompressed with a 10 Foley catheter duodenostomy. The estimated blood loss was 5 units of whole blood. Six units of whole blood were replaced. The postoperative course was relatively uneventful and the duodenostomy was removed on the ninth postinjury day. The patient was discharged on the eleventh postinjury day. DONALD TRUNKEY, MD: t We have asked Dr. Robert Lim, Associate Professor of Surgery and Chief of our Emergency Department, to discuss the management of vascular injuries of the abdomen. Dr. Lim, this case does not represent the typical large vessel injury we see because the patient was in compensated shock when she arrived. But using her as the focal point, would you discuss these injuries? ROBERT C. LIM, MD:$ I would like to begin the discussion by pointing out the relative frequency of this type of injury. In 1972 we reviewed all tAssistant Professor of Surgery, San Francisco General Hos-
pital.
tAssociate Professor of Surgery, and Chief of Mission Emergency Service, San Francisco General Hospital.
THE WESTERN JOURNAL OF MEDICINE
321
ABDOMINAL VASCULAR INJURIES
trauma deaths in San Francisco. Of these, 150 patients (35.2 percent) died from injuries resulting from hemorrhage. Eight were secondary to either blunt or penetrating wounds of the aorta. We were stimulated by these statistics to review those major aortic injuries which reached San Francisco General Hospital. In the last five years there were 32 patients who survived their injury long enough to reach the emergency room. All but three of the patients presented at the emergency room in profound shock. Half had dilated fixed pupils and no palpable blood pressure. I should add parenthetically that we do not consider an unobtainable pressure and fixed dilated pupils as a sign of an irreversible injury. In the past year we have successfully resuscitated eight such patients and only one had significant neurological residual. In reviewing the 32 aortic injuries treated at San Francisco General, we divided them into three major groups: injuries to the diaphragmatic aorta, the suprarenal aorta and the infrarenal aorta. Roughly half of those patients with injuries of the diaphragmatic aorta or infrarenal aorta survived but only 11 percent of patients with injuries of the aorta between the celiac artery and renal arteries lived. This is because associated injuries of one or more of the important structures, such as pancreas and liver, in this area are common and contribute to the very high mortality. Associated injuries are the rule in all aortic injuries, and most of our patients had accompanying injuries of the bowel, mesentery and solid organs. First, I would like to comment on the resuscitation of any patient who presents in profound shock. Large bore cutdowns in multiple sites (basilic vein of the arm and saphenous ve"in of the ankle) are required. Infusion of balanced salt solution should be begun immediately after blood is drawn for typing and cross-matching. If the patient responds to the fluid resuscitation, further assessment may be carried out. When there has been major abdominal vessel injury the patient usually does not respond and immediate operative intervention is required. As a general rule whole blood administration is not done in the emergency room and is reserved until control of the major bleeding is obtained. Otherwise blood is wasted as it continues to bleed into body cavities and is not available for the final phase of resuscitation. Cardiac surgical experience has shown that patients do well on hemodilution and resuscitation may actually be enhanced. It is not until hemo-
322
OCTOBER 1975 * 123 * 4
dilution produces an hematocrit below 20 that oxygen carrying capacity is significantly interfered with. Any center dealing with large numbers of trauma patients should maintain reserves of blood of all the common types. The use of type specific blood in a trauma patient receiving massive transfusions is preferable to type 0 negative blood. We feel this has been a very important point in avoiding some of the minor mismatch problems which are magnified when such a patient receives large quantities of transfused blood. The case presented today points out another factor necessary for survival. There must be a high index of suspicion at major vessel injury especially when a patient presents in profound shock and does not respond promptly to fluid resuscitation. While major abdominal vascular injury is relatively rare with blunt trauma, it should be suspected when the violence is severe as documented by other associated injuries. The last point I wish to make in regard to management of these injuries in the emergency room is that with cardiac arrest or arrests during resuscitation we advocate opening the chest with a left sixth interspace thoracotomy incision in order to institute open chest massage and to crossclamp the supradiaphragmatic aorta. This may permit salvage of what is otherwise a hopeless situation. When the heart is empty or when cardiac tamponade has occurred, closed cardiac massage is futile and more effective circulatory support can be provided through the open chest. The ready accessibility of the descending thoracic aorta through the left chest permits prompt control of intraabdominal arterial bleeding so that volume can be restored and cerebral perfusion ensured. Occlusion of the thoracic aorta will direct whatever blood volume is left towards the heart and brain. In the group of aortic injuries which we reviewed, all but three of the patients presented to the emergency room in shock. In half the patients, there were cardiac arrests in the emergency room. Open cardiac resuscitation and aortic crossclamping were found to be helpful in resuscitating these patients. A PHYSICIAN: How does a surgeon gain control of the aortic injuries at the various sites? DR. LIM: It will vary depending on the section of the aorta that is injured. If the injury is in the upper abdominal aorta it may be necessary to open into the left chest through the sixth or
ABDOMINAL VASCULAR INJURIES
seventh intercostal space and gain proximal control of the aorta above the diaphragm. Access to the injury itself is then gained by making an incision along the left lateral peritoneal reflection and mobilizing the left colon, the spleen and the tail of the pancreas towards the right. This will allow exposure of the aorta from the diaphragm to the iliac bifurcation (Figure 1). It may also be necessary to take down part of the crus of the diaphragm to gain access to the very uppermost portion of the abdominal aorta. In injuries to the infrarenal aorta, exposure can be gained by reflection of the left colon alone or by paraduodenal approach, much as one approaches a patient with a ruptured abdominal aortic aneurysm. A PHYSICIAN: What about the patient who sustains a major intra-abdominal vascular injury in a remote or rural area and there is no trauma center? What do you do then? DR. LIM: In those particular instances there has been interest in investigating the use of the Medi-
cal Anti-Shock Trouser (MAST), to slow or stabilize bleeding long enough to permit transport of the patient. These trousers are a threecompartment inflatable suit that fits snugly around the waist and both legs. They are inflatable to 80 mm of mercury. These trousers functionally occlude the aorta at the diaphragm. It is not known at the present time how long these trousers can be left on, but it is safe to say that a patient could certainly tolerate up to an hour of transportation with these pants. The surgeon who is going to remove these pants must be prepared to deal with the consequences of suddenly declamping the aorta. DR. TRUNKEY: Dr. Lim, would you mention the significance of declamping shock?
DR. LIM: An entity called hidden acidosis has been described which results from low perfusion in the region supplied by the temporarily occluded aorta. Anaerobic metabolism at the tissue level will lead to accumulation of lactate acid and acid by-products of metabolism in the ischemic tissues which is not reflected in the systemic circulation during the period of vascular occlusion. When circulation is restored by removal of the aortic clamp there is a washout of these acid metabolites into the general circulation and these have profound effects on cardiovascular dynamics. Years ago, we did a number of studies measuring the pH of blood coming from the extremities after aortic occlusion and found the pH was often around 6. This acid load will depress myocardial function when the notably dilated vascular bed is opened up. The anesthesiologist must be ready to administer sodium bicarbonate and infuse fluids rapidly as the clamp is removed. If this is not done profound hypotension due to sequestration of volume in the lower extremity combined with myocardial depression will lead to cardiac arrest. F. WILLIAM BLAISDELL, MD: * Dr. Lim, would you like to make a few comments on the management of major venous injury within the abdomen?
I
II
II
0I
Figure 1.-Rapid exposure of abdominal aorta.
DR. LIM: There is one very important factor that should guide you in the repair of any venous injury in the abdomen. This is the amount and extent of associated injuries. I think we waste too much time trying to repair venous injuries. There are only two that absolutely require repair: the *Chief of Surgical
Service,
San Francisco General Hospital.
THE WESTERN JOURNAL OF MEDICINE
323
ABDOMINAL VASCULAR INJURIES
suprarenal cava and the portal venous system. All other venous injuries within the abdomen may be safely ligated with no untoward sequelae. Ligation is indicated if there are other major injuries such as an aortic injury or major liver or pancreatic injury. The reason for this is two-fold. Ill advised attempts to repair the vein may lead to further blood loss. In addition, the area of the repair is a potential source for thromboembolic complications. The greater the number of associated injuries, the greater this theoretical hazard. In those venous injuries where there are not extensive associated injuries and the patient is not in shock, then an attempt at lateral repair may be made. I would not do so, however, at the expense of further blood loss which unduly prolongs the operation.
A PHYSICIAN: Would you ligate an injury to a renal vein? DR. LIM: Yes. It has been shown in surgical procedures done for portal hypertension and also in other operations dealing with renal veins that ligation of renal veins is well tolerated. The kidney will do quite well as collaterals developed in the capsule. Another major source of collateral venous drainage for the kidney is by the way of the gonadal and adrenal branches.
A PHYSICIAN: Does clamping the aorta control venous hemorrhage? DR. LiM: No. Venous bleeding will continue despite crossclamping of the aorta. Major caval injuries will continue to hemorrhage in a retrograde manner just as readily after aortic clamping as before. The best way to gain control of major venous hemorrhage is by packing or direct compression of the injury. The venous system is a low pressure system and judicious use of pressure will temporarily control almost all venous bleeding. We do not routinely advocate use of vascular clamps on venous injuries since they are apt to tear the vein and cause further damage. In closing, I would like to reemphasize that when one does not know the exact location of an injury to the aorta, rapid exposure of the entire abdominal aorta may be obtained by incising and reflecting the peritoneal attachment of the left colon along with the spleen and tail of the pancreas to the right. If there should be bleeding from the posterior aspect of the aorta, the kidney may be mobilized from its bed and also reflected over to the right. In this way one can secure any posterior injury of the aorta or any tangential injury of the aorta. If difficulty is still encountered in securing the posterior injury one can carry out an anterior aortotomy or enlarge an existing anterior injury so that one can repair the back wall of the aorta from within the lumen.
CORRECTION IN THE ARTICLE "Manganese Intoxication," which appeared in the August 1975 issue of the JOURNAL, an error in editing was made which indicated that the concentration of manganese in ambient air is 0.1 microgram per cu mm. The second sentence, page 101, should read "The ambient air concentration averages 0.1 microgram (0g) per cubic meter."
324
OCTOBER 1975 * 123 * 4
Trauma oun
s
Chief Discussant ROBERT C. LIM, MD
Editors DONALD D. TRUNKEY, MD F. WILLIAM BLAISDELL, MD
Abdominal Vascular Injuries
This is one of a series of Conferences on Trauma at San Francisco General Hospital
WILLIAM COPELAND, MD: * The patient is a 16year-old Latin American girl who was admitted with a self-inflicted gunshot wound of the right epigastrium. The exit wound was above the left iliac crest posteriorly. When first evaluated in the emergency room, blood pressure was 130/80 mm of mercury and pulse was 110 and regular. However, peripheral perfusion was decreased as shown by cool, pale extremities. Sensorium was intact. No abnormalities were noted on initial urinalysis and the urine was found to be without red cells. After placement of a large-bore cutdown and rapid infusion of Ringer's lactate solution, the patient was moved to the x-ray department so that films of the chest and abdomen could be made. The film of the chest showed no abnormalities. During the radiological examination an expanding mass in the left lower quadrant was noted and films of the abdomen confirmed this. Immediate exploration of the abdomen showed the following injuries (1) a through and through laceration of the right gastroepiploic artery and vein, (2) a through and through wound of the third portion of the duodenum, (3) a wound of the infrarenal aorta approximately 1 cm in size with extensive retroperitoneal bleeding. The bul*Intern, Trauma Service, San Francisco General Hospital. Sponsored by the American College of Surgeons Northern California Trauma Committee. Supported in part by NIH Grant GM18470. Reprint requests to: Donald D. Trunkey, MD, Department of Surgery, San Francisco General Hospital, San Francisco CA 94110.
let exited through the left psoas muscle, lacerating a lumbar artery. Proximal and distal control of the aortic injury was obtained and the laceration was sutured with running 4-0 vascular suture. The gastroepiploic artery was ligated and the duodenal wounds were closed with a double layer technique. The duodenum was decompressed with a 10 Foley catheter duodenostomy. The estimated blood loss was 5 units of whole blood. Six units of whole blood were replaced. The postoperative course was relatively uneventful and the duodenostomy was removed on the ninth postinjury day. The patient was discharged on the eleventh postinjury day. DONALD TRUNKEY, MD: t We have asked Dr. Robert Lim, Associate Professor of Surgery and Chief of our Emergency Department, to discuss the management of vascular injuries of the abdomen. Dr. Lim, this case does not represent the typical large vessel injury we see because the patient was in compensated shock when she arrived. But using her as the focal point, would you discuss these injuries? ROBERT C. LIM, MD:$ I would like to begin the discussion by pointing out the relative frequency of this type of injury. In 1972 we reviewed all tAssistant Professor of Surgery, San Francisco General Hos-
pital.
tAssociate Professor of Surgery, and Chief of Mission Emergency Service, San Francisco General Hospital.
THE WESTERN JOURNAL OF MEDICINE
321
ABDOMINAL VASCULAR INJURIES
trauma deaths in San Francisco. Of these, 150 patients (35.2 percent) died from injuries resulting from hemorrhage. Eight were secondary to either blunt or penetrating wounds of the aorta. We were stimulated by these statistics to review those major aortic injuries which reached San Francisco General Hospital. In the last five years there were 32 patients who survived their injury long enough to reach the emergency room. All but three of the patients presented at the emergency room in profound shock. Half had dilated fixed pupils and no palpable blood pressure. I should add parenthetically that we do not consider an unobtainable pressure and fixed dilated pupils as a sign of an irreversible injury. In the past year we have successfully resuscitated eight such patients and only one had significant neurological residual. In reviewing the 32 aortic injuries treated at San Francisco General, we divided them into three major groups: injuries to the diaphragmatic aorta, the suprarenal aorta and the infrarenal aorta. Roughly half of those patients with injuries of the diaphragmatic aorta or infrarenal aorta survived but only 11 percent of patients with injuries of the aorta between the celiac artery and renal arteries lived. This is because associated injuries of one or more of the important structures, such as pancreas and liver, in this area are common and contribute to the very high mortality. Associated injuries are the rule in all aortic injuries, and most of our patients had accompanying injuries of the bowel, mesentery and solid organs. First, I would like to comment on the resuscitation of any patient who presents in profound shock. Large bore cutdowns in multiple sites (basilic vein of the arm and saphenous ve"in of the ankle) are required. Infusion of balanced salt solution should be begun immediately after blood is drawn for typing and cross-matching. If the patient responds to the fluid resuscitation, further assessment may be carried out. When there has been major abdominal vessel injury the patient usually does not respond and immediate operative intervention is required. As a general rule whole blood administration is not done in the emergency room and is reserved until control of the major bleeding is obtained. Otherwise blood is wasted as it continues to bleed into body cavities and is not available for the final phase of resuscitation. Cardiac surgical experience has shown that patients do well on hemodilution and resuscitation may actually be enhanced. It is not until hemo-
322
OCTOBER 1975 * 123 * 4
dilution produces an hematocrit below 20 that oxygen carrying capacity is significantly interfered with. Any center dealing with large numbers of trauma patients should maintain reserves of blood of all the common types. The use of type specific blood in a trauma patient receiving massive transfusions is preferable to type 0 negative blood. We feel this has been a very important point in avoiding some of the minor mismatch problems which are magnified when such a patient receives large quantities of transfused blood. The case presented today points out another factor necessary for survival. There must be a high index of suspicion at major vessel injury especially when a patient presents in profound shock and does not respond promptly to fluid resuscitation. While major abdominal vascular injury is relatively rare with blunt trauma, it should be suspected when the violence is severe as documented by other associated injuries. The last point I wish to make in regard to management of these injuries in the emergency room is that with cardiac arrest or arrests during resuscitation we advocate opening the chest with a left sixth interspace thoracotomy incision in order to institute open chest massage and to crossclamp the supradiaphragmatic aorta. This may permit salvage of what is otherwise a hopeless situation. When the heart is empty or when cardiac tamponade has occurred, closed cardiac massage is futile and more effective circulatory support can be provided through the open chest. The ready accessibility of the descending thoracic aorta through the left chest permits prompt control of intraabdominal arterial bleeding so that volume can be restored and cerebral perfusion ensured. Occlusion of the thoracic aorta will direct whatever blood volume is left towards the heart and brain. In the group of aortic injuries which we reviewed, all but three of the patients presented to the emergency room in shock. In half the patients, there were cardiac arrests in the emergency room. Open cardiac resuscitation and aortic crossclamping were found to be helpful in resuscitating these patients. A PHYSICIAN: How does a surgeon gain control of the aortic injuries at the various sites? DR. LIM: It will vary depending on the section of the aorta that is injured. If the injury is in the upper abdominal aorta it may be necessary to open into the left chest through the sixth or
ABDOMINAL VASCULAR INJURIES
seventh intercostal space and gain proximal control of the aorta above the diaphragm. Access to the injury itself is then gained by making an incision along the left lateral peritoneal reflection and mobilizing the left colon, the spleen and the tail of the pancreas towards the right. This will allow exposure of the aorta from the diaphragm to the iliac bifurcation (Figure 1). It may also be necessary to take down part of the crus of the diaphragm to gain access to the very uppermost portion of the abdominal aorta. In injuries to the infrarenal aorta, exposure can be gained by reflection of the left colon alone or by paraduodenal approach, much as one approaches a patient with a ruptured abdominal aortic aneurysm. A PHYSICIAN: What about the patient who sustains a major intra-abdominal vascular injury in a remote or rural area and there is no trauma center? What do you do then? DR. LIM: In those particular instances there has been interest in investigating the use of the Medi-
cal Anti-Shock Trouser (MAST), to slow or stabilize bleeding long enough to permit transport of the patient. These trousers are a threecompartment inflatable suit that fits snugly around the waist and both legs. They are inflatable to 80 mm of mercury. These trousers functionally occlude the aorta at the diaphragm. It is not known at the present time how long these trousers can be left on, but it is safe to say that a patient could certainly tolerate up to an hour of transportation with these pants. The surgeon who is going to remove these pants must be prepared to deal with the consequences of suddenly declamping the aorta. DR. TRUNKEY: Dr. Lim, would you mention the significance of declamping shock?
DR. LIM: An entity called hidden acidosis has been described which results from low perfusion in the region supplied by the temporarily occluded aorta. Anaerobic metabolism at the tissue level will lead to accumulation of lactate acid and acid by-products of metabolism in the ischemic tissues which is not reflected in the systemic circulation during the period of vascular occlusion. When circulation is restored by removal of the aortic clamp there is a washout of these acid metabolites into the general circulation and these have profound effects on cardiovascular dynamics. Years ago, we did a number of studies measuring the pH of blood coming from the extremities after aortic occlusion and found the pH was often around 6. This acid load will depress myocardial function when the notably dilated vascular bed is opened up. The anesthesiologist must be ready to administer sodium bicarbonate and infuse fluids rapidly as the clamp is removed. If this is not done profound hypotension due to sequestration of volume in the lower extremity combined with myocardial depression will lead to cardiac arrest. F. WILLIAM BLAISDELL, MD: * Dr. Lim, would you like to make a few comments on the management of major venous injury within the abdomen?
I
II
II
0I
Figure 1.-Rapid exposure of abdominal aorta.
DR. LIM: There is one very important factor that should guide you in the repair of any venous injury in the abdomen. This is the amount and extent of associated injuries. I think we waste too much time trying to repair venous injuries. There are only two that absolutely require repair: the *Chief of Surgical
Service,
San Francisco General Hospital.
THE WESTERN JOURNAL OF MEDICINE
323
ABDOMINAL VASCULAR INJURIES
suprarenal cava and the portal venous system. All other venous injuries within the abdomen may be safely ligated with no untoward sequelae. Ligation is indicated if there are other major injuries such as an aortic injury or major liver or pancreatic injury. The reason for this is two-fold. Ill advised attempts to repair the vein may lead to further blood loss. In addition, the area of the repair is a potential source for thromboembolic complications. The greater the number of associated injuries, the greater this theoretical hazard. In those venous injuries where there are not extensive associated injuries and the patient is not in shock, then an attempt at lateral repair may be made. I would not do so, however, at the expense of further blood loss which unduly prolongs the operation.
A PHYSICIAN: Would you ligate an injury to a renal vein? DR. LIM: Yes. It has been shown in surgical procedures done for portal hypertension and also in other operations dealing with renal veins that ligation of renal veins is well tolerated. The kidney will do quite well as collaterals developed in the capsule. Another major source of collateral venous drainage for the kidney is by the way of the gonadal and adrenal branches.
A PHYSICIAN: Does clamping the aorta control venous hemorrhage? DR. LiM: No. Venous bleeding will continue despite crossclamping of the aorta. Major caval injuries will continue to hemorrhage in a retrograde manner just as readily after aortic clamping as before. The best way to gain control of major venous hemorrhage is by packing or direct compression of the injury. The venous system is a low pressure system and judicious use of pressure will temporarily control almost all venous bleeding. We do not routinely advocate use of vascular clamps on venous injuries since they are apt to tear the vein and cause further damage. In closing, I would like to reemphasize that when one does not know the exact location of an injury to the aorta, rapid exposure of the entire abdominal aorta may be obtained by incising and reflecting the peritoneal attachment of the left colon along with the spleen and tail of the pancreas to the right. If there should be bleeding from the posterior aspect of the aorta, the kidney may be mobilized from its bed and also reflected over to the right. In this way one can secure any posterior injury of the aorta or any tangential injury of the aorta. If difficulty is still encountered in securing the posterior injury one can carry out an anterior aortotomy or enlarge an existing anterior injury so that one can repair the back wall of the aorta from within the lumen.
CORRECTION IN THE ARTICLE "Manganese Intoxication," which appeared in the August 1975 issue of the JOURNAL, an error in editing was made which indicated that the concentration of manganese in ambient air is 0.1 microgram per cu mm. The second sentence, page 101, should read "The ambient air concentration averages 0.1 microgram (0g) per cubic meter."
324
OCTOBER 1975 * 123 * 4
