Lower abdominal, pelvic and urological trauma carry particular challenges for battlefield surgeons. Following experience in Afghanistan, Mark Mantle and Graham Sunderland consider approaches
CT of gunshot wound to the left axilla with injury to the spleen and left kidney.
The Defence Medical Services are gaining unparalleled experience in the management of penetrating trauma due to the tempo of operations in Afghanistan. 205 Scottish Field Hospital (a Territorial Army Unit) spent six months deployed at Camp Bastion in Helmand province in early 2010. This period included Operation Moshtarak and its aftermath and provided a very busy and challenging tour for the hospital staff.
The ‘signature injury’ experienced during 205’s tour was that inflicted by the improvised explosive device (IED), but we also encountered gunshot and other fragmentation injuries. With continued improvements in pre-hospital care, military medics face increasingly challenging cases, including many that would previously have been non-survivable.
This article aims to relate some of the experience gained in the management of penetrating lower abdominal, pelvic and urological injury.
Pelvic trauma
Ballistic pelvic trauma is particularly challenging to the battlefield surgeon. It carries a high immediate mortality of approximately 10%, rising to more than 40% if there is a major arterial injury and shock. It is also associated with combined injuries to multiple organs: urethra, bladder, rectum and bone.
Case one
A Taliban fighter was brought in by helicopter with a gunshot wound to the pelvis. He had already undergone 15 minutes of cardiopulmonary resuscitation en route, but on arrival in the emergency department (ED) was proven to have cardiac activity on an electrocardiogram and ultrasound. He was therefore ‘right turned’ into the operating theatre for continued resuscitation and immediate laparotomy. It became clear that he had suffered a massive bleed into the pelvis.
The first manoeuvre, after performing a midline laparotomy incision, was to pack the abdomen and pelvis. Proximal control was achieved by cross clamping the aorta. At this point, surgeons stopped and the anaesthetists had a chance to catch up. This involved blood transfusion including fresh frozen plasma and real time assessment of clotting status using thromboelastography. This technology is being trialed in the field hospital setting to give a global clotting profile allowing targeted treatment with FFP, platelets or specific clotting factors.
On improvement in his haemodynamic status, the surgeons identified the iliac artery and vein on the side that was bleeding and gained control of both with clamps. A large defect was identified in the iliac vein and over sewn. The patient still had significant oozing from a bone injury. Celox™ gauze and packing were used to try and gain control. Celox™ (which comes as granules or a gauze) stops bleeding by bonding with red blood cells and gelling with fluids to produce a sticky pseudo clot and has been found to be effective in controlling difficult bleeding. At this point, a systematic laparotomy was performed and an associated small bowel injury repaired.
The patient continued to bleed and despite further exploration no obvious bleeding point could be identified. Packs were positioned, a laparostomy closure employed and the patient moved to the intensive care unit. No improvement was seen with further resuscitative efforts and he died on the ITU.
This case highlights the difficulties of dealing with pelvic bleeding and the importance of teamwork. Good communication between ED staff, surgeons, scrub team, anaesthetists and laboratory staff is essential when managing these patients. Coagulopathy in the trauma patient is a major factor in bleeding and is multifactorial. Hypothermia, haemodilution, acidosis and fibrinolysis all contribute. It is necessary to identify clotting abnormalities quickly and accurately and treat them aggressively. This methodology has been termed "damage control resuscitation".
Renal injuries
Renal injuries are relatively common in penetrating abdominal trauma. The easy access to CT scanning at Camp Bastion meant these patients could have their injuries graded accurately. CT also confirms the presence of a normal and functioning kidney on the contralateral side, which is important should the need for surgical exploration of the injured kidney become necessary. Renal trauma is most commonly managed conservatively unless the patient is unstable or an expanding lateral retroperitoneal haematoma is encountered at laparotomy.
Case two
A suicide bomber had detonated next to a gathering of local people. 18 patients were brought to Bastion by helicopter, but five were either dead on arrival or died shortly after. A 12-year-old Afghan child was one of those admitted. He had multiple penetrating fragment injuries to his back and buttocks but was haemodynamically stable. CT images revealed a grade 4 left renal injury but there was also concern about associated abdominal injuries and he was taken to theatre for a laparotomy. At laparotomy he was found to have several small bowel injuries, which were repaired. On inspection of the retroperitoneum it was noted that he had a lateral haematoma which was non expansile. He remained haemodynamically stable and therefore this was not explored further. His wounds were debrided and washed thoroughly. Post operatively he did very well but was advised to remain on bed rest for two weeks.
In these patients, there is a risk of re-bleeding which, in the UK, can be managed by selective embolisation. The lack of this option in Afghanistan as well as the rapid movement of local casualties to other medical facilities with variable expertise meant a lower threshold for nephrectomy in these patients. This was the case in an ANA soldier shot through the left axilla with splenic and significant grade 4 left renal injury. He had been haemodynamically unstable on admission but had stabilised and the retroperitoneal haematoma was nonexpansile. Because of the severity of the injury and difficulties with post operative care it was decided to remove the kidney.
Perineal injuries
We saw a small but significant number of patients with penile and testicular injuries secondary to IEDs. These patients often had bilateral lower limb amputations and were occasionally associated with devastating perineal injuries. Urethral injuries must be looked for and either urethral or suprapubic catheterization used as appropriate. The loss of testicular and penile tissue has implications on sexual function and fertility and obviously has major psychological implications.
Case three
A young British soldier was admitted following an IED explosion. He had bilateral traumatic lower limb amputations and had also lost an arm. Bleeding was controlled with tourniquets and he was haemodynamically stable after initial resuscitation. On further examination he had a minor penile injury but had lost all of his right testicular tissue and had a left testicular rupture. His perineum was intact. Having transferred him to theatre the surgical priority was to gain proximal control at external iliac level. This allowed debridement and completion amputation of his lower limbs. Debridement of the penis was performed but there was no cavernosal or urethral injury. As a urologist was available the left testis was explored and a repair performed.
In these patients, testicular debridement should be kept to a minimum and if only one damaged testis remains, then the guidance is to simply wash and dress in Vaseline gauze leaving further management to urological specialists at a Role 4 facility (following evacuation back to the UK). The emphasis is maintaining as much testicular tissue as possible which, even in severe injuries, can allow for sperm harvesting once back in the UK.
Conclusion
The management of trauma patients in this setting (Role 3) is aimed at resuscitation and stabilisation prior to evacuation to a Role 4 facility for definitive treatment. Controlling bleeding and contamination are the main priorities. This requires a teamwork approach with an emphasis on communication.
Mark Mantle and Graham Sunderland
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