Source
Department of Surgery, Walter Reed Army Medical Center, Washington, DC 20307, USA. charles.fox@us.army.mil
Abstract
OBJECTIVES:
Major vascular injury is a leading cause of potentially preventable hemorrhagic death in modern combat operations. An optimal resuscitation approach for military trauma should offer both rapid hemorrhage control and early reversal of metabolic derangements. The objective of this report is to establish the use and effectiveness of a damage control resuscitation (DCR) strategy in the setting of wartime vascular injury.
METHODS:
A retrospective two-cohort case control study was performed using the Joint Theater Trauma Registry to identify patients with an extremity vascular injury treated at two different points in time: group 1 (n = 16) from April to June 2006 when DCR concepts were put into practice and group 2 (n = 24) 1 year later in a period when DCR strategies were not employed.
RESULTS:
Baseline demographics, injury severity, admission physiology, and operative details were similar between groups 1 and 2. Group 1 patients received more total blood products (23 vs. 12 units, p < 0.05), fresh frozen plasma (16 vs. 7 units, p < 0.01), cryoprecipitate (11 vs. 1.2 units, p < 0.05), whole blood (19% vs. 0%, p = 0.06), and early recombinant factor VIIa (75% vs. 0%, p < 0.001) than group 2 patients. Group 1 patients had a more complete early physiologic recovery after vascular reconstruction (heart rate: 38 vs. 12, p < 0.001; systolic blood pressure, 39 vs. 14, p < 0.001; base deficit: 7.36 vs. 2.72, p < 0.001; International Normalized Ratio, 0.3 vs. 0.1, p < 0.001). There was no significant difference in early amputation rates (group 1: 6.2% vs. group 2: 4.2%) or 7-day mortality (0% in both groups).
CONCLUSIONS:
This study was the first to use the Joint Theater Trauma Registry for follow-up on an established clinical practice guideline. DCR goals appear now to be met during the management of acute wartime vascular injuries with effective correction of physiologic shock. The overall impact of this resuscitation strategy on long-term outcomes such as limb salvage and mortality remains to be determined.