DTIC ADA619947: Noncompressible Torso Hemorrhage: A Review with Contemporary Definitions and Management Strategies

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Noncompressible Torso
Hemorrhage
A Review with Contemporary Definitions and
Management Strategies
Jonathan J. Morrison, MB,ChB,MRCSa,b,
Todd E. Rasmussen, MDb,c,d,*
KEYWORDS
(cid:1)Noncompressibletorsohemorrhage (cid:1)Traumasurgery (cid:1) Militarysurgery
(cid:1)Damage-controlsurgery (cid:1) Damage-controlresuscitation
KEYPOINTS
(cid:1) Vascular disruption with concomitant hemorrhage is the leading cause of potentially
preventabledeathinbothcivilianandmilitarytrauma.Ifthisoccursinthetorsoorinajunc-
tionalarea,itistermednoncomressibletorsohemorrhage(NCTH).
(cid:1) AlthoughtheconceptofNCTHisintuitive,thereremainsnoformaldefinitionbywhichto
characterizethescopeoftheproblemandcompareinterventions.
(cid:1) A novel and inclusive definition using anatomic, physiologic, and procedural criteria
enablestheidentificationofpatientswithNCTH.
(cid:1) Management requires rapid intervention including damage-control resuscitation and
surgerywithanemphasisonearlyhemostasis.
(cid:1) Despite the emergence of new strategies such as damage-control resuscitation and
adjuncts such as endovascular surgery, the principles of proximal and distal vascular
controlareessential.
Theauthorshavenothingtodisclose.Theviewsandopinionsexpressedinthisarticlearethose
of the authors and do not reflect the official policy or position of the US Air Force, US
DepartmentofDefense,ortheUSGovernment.
a TheAcademicDepartmentofMilitarySurgery&Trauma,RoyalCentreforDefenceMedicine,
BirminghamResearchPark,VincentDrive,Edgbaston,BirminghamB152SQ,UnitedKingdom;
b U.S.ArmyInstituteofSurgicalResearch,3400RawleyEastChambersAvenue,SuiteB,FortSam
Houston, TX 78234, USA; c U.S. Air Force Medical Service, 59th Medical Deployment Wing,
Science and Technology Section, 2200 Bergquist Drive, Suite 1, Lackland Air Force Base, TX
78236,USA;d TheNormanM.RichDepartmentofSurgery,theUniformedServicesUniversity
oftheHealthSciences,4301JonesBridgeRoad,Bethesda,MD20814,USA
*Correspondingauthor.USArmyInstituteofSurgicalResearch,3400RawleyEastChambers
Avenue,SuiteB,FortSamHouston,TX782346315.
Emailaddress:[email protected]
SurgClinNAm92(2012)843 858
doi:10.1016/j.suc.2012.05.002 surgical.theclinics.com
00396109/12/$ seefrontmatterPublishedbyElsevierInc.
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Noncompressible torso hemorrhage: a review with contemporary
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INTRODUCTION
Vascular disruption with hemorrhage remains a leading cause of death in both
civilian1,2 and wartime trauma.3,4 Broadly classified, hemorrhage occurs from either
compressible sites, meaning those locations amenable to immediate control with
manual pressure or tourniquet application, or from noncompressible sites, meaning
locations not amenable to control with direct pressure or tourniquet application
(Fig.1).5Intheciviliansetting,hemorrhageispresentin15%to25%ofadmissions,
andstudiesfromthewarsinAfghanistanandIraqshowthattherateofvascularinjury
incombatisapproximately10%.4–6Althoughextremityinjuryisoverallmostcommon,
thefocusofthisreviewisonthemanagementofvasculardisruptionandhemorrhage
fromsourceswithinthetorso,includingthethorax,abdomenandpelvis,oncethese
patients reach definitive care. An excellent review of the prehospital management
strategiesfortheseinjuriesisprovidedbyKerbyandCusickelsewhereinthisissue.7
HEMORRHAGEASAPROBLEMINTRAUMA
Controlofbleedingfromvasculardisruptionwithinthetorsoisnotreadilyamenableto
control with direct pressure and is therefore referred to as noncompressible torso
Fig. 1. The shaded area denotes the region where noncompressible torso hemorrhage is
anatomically located. (From Blackbourne LH, Czarnik J, Mabry R, et al. Decreasing killed
in action and died of wounds rates in combat wounded. J Trauma Inj Infect Crit Care
2010;69(1):S1;withpermission.)
NoncompressibleTorsoHemorrhage 845
hemorrhage(NCTH).CivilianstudiesdemonstratingthatNCTHaccountsfor60%to
70%ofmortalityfollowingotherwisesurvivableinjuries(ie,nolethalheadorcardiac
wounds)clearlyemphasizesthelethalityofthisinjurypattern.1,2Hemorrhageisalso
a significant problem in the wartime setting, accounting for up to 60% of deaths in
potentiallysurvivableinjuryscenario.7,8StudiesonthosekilledinactioninAfghanistan
and Iraq have shown that of deaths occurring in the setting of otherwise survivable
injuries,3 80% were a result of bleeding from within the torso.4,5 The distinction
betweencompressible extremityhemorrhageandNCTHisnotable.Therehasbeen
ademonstrablereductioninmortalityfromextremityinjurywithabetterunderstanding
ofitsepidemiologyandtheneedtorapidlycontrolhemorrhagewithtourniquetsand/
ortopicalhemostaticagents.8Todate,therehasbeennosuchreductioninmortality
inthesettingofNCTH.
DEFINITION
Theseobservationshaveresultedinathrustwithinthecombatcasualtycareresearch
communitytobetterdefineandclassifylocationsandpatternsofNCTH.Despiteits
obvioussignificance,untilthewarsinAfghanistanandIraqaconsensusdefinitionof
NCTHwaslacking.Recentlyreportshaveemergedfromthemilitary’sJointTrauma
Systemandselectcivilianinstitutionsproposingaunifyingclassificationofthisinjury
pattern.Ithasbeentheaimofthesestudiestoestablishacohesivedefinitionallowing
forstudyoftheepidemiologyofthisproblemandcomparisonofmanagementstrate-
gies,inhopesofreducingmortality.Untiltheserecentreports,studiesofinjurieswithin
thetorsofocusedonspecificorganinjuriessuchasaseriesofliverinjuriesorfellalong
specialtyboundariessuchasavascularsurgeon’sapproachtoiliacarteryrepair.
ThewartimeperspectiveonNCTHworksfromthepremisethatvasculardisruption
withbleedingcanarisefromanarrayofanatomicsites:
(cid:1) Largeaxialvessels
(cid:1) Solidorganinjuries
(cid:1) Pulmonaryparenchymalinjuries
(cid:1) Complexpelvicfractures.
Assuch,thecontemporarydefinitionofNCTHbeginswiththepresenceofvascular
disruptionfrom1ormoreof4anatomiccategorieslistedinTable1.Cardiacwounds
arenotincludedwithinthisdefinition,giventheirhighmortality.
Toidentifyonlypatientswithactivehemorrhagefromtheseanatomiccategories,the
definitionofNCTHincludesthepresenceofphysiologicmeasuresoroperativeproce-
dures that reflect hemodynamic instability and/or the need for urgent hemorrhage
control.Theseincludehypotensionorshockandtheneedforemergentlaparotomy,
thoracotomy, or a procedure to manage bleeding from a complex pelvic fracture.
Table1
Noncompressibletorsohemorrhage(NCTH)
AnatomicCriteria Hemodynamic/ProceduralCriteria
1.Thoraciccavity(includinglung)
2.Solidorganinjury(cid:3)grade4(liver,kidney, Hemorrhagicshocka;orneedforimmediate
spleen) operation
3.Namedaxialtorsovessel
4.Pelvicfracturewithringdisruption
a Definedasasystolicbloodpressure<90mmHg.
846 Morrison&Rasmussen
Absentthephysiologicorproceduralinclusioncriteria,thedefinitionofNCTHwouldbe
prone to include injuries with the at-risk anatomic category that were not actively
bleeding.Thisarticlereviewsthemilitaryandcivilianexperiencewithnoncompressible
torsohemorrhage,andprovidesanoverviewofsurgicalandresuscitativestrategies.
MILITARYANDCIVILIANPERSPECTIVES
OneofthefirststudiestorecognizetheimportanceofuncontrolledtruncalwasbyHol-
comb and colleagues,5 who reviewed autopsy findings of special operations forces
personnel killed early in the wars in Afghanistan and Iraq, between 2001 and 2004.
Apanelofexpertsreviewedtherecordsof82fatalitiesandjudgedthemasnonsurviv-
able(eg,lethalheadorcardiacwounds)orpotentiallysalvageable.Thisstudywasone
of the first to specifically use the term “noncompressible truncal hemorrhage,”
although it was not specifically defined. NCTH was found to be the cause of death
in50%ofpatientsjudgedtohavesustainedpotentiallysurvivableinjuries.
Kellyandcolleagues4usedasimilarmethodologytoanalyze997UnitedStatesmili-
tarydeathsthatoccurredwithin2timeperiods:2003to2004and2006.Hemorrhage
was the leading cause of death in those with otherwise survivable injuries, and
accountedfor87%and83%ofdeathsduringtheserespectiveperiods.Airwayprob-
lems,headinjury,andsepsisconstitutedtheremainingcausesofdeath.
Withinthehemorrhagegroup,50%wereduetoNCTHand33%toextremityhemor-
rhage (amenable to tourniquet application). This study also introduced hemorrhage
from another distinct anatomic and clinically important location: junctional areas
between the torso and the extremities. Junctional vascular injury or hemorrhage
from the proximal femoral or axillobrachial vessels is often not amenable to direct
pressure or application of a tourniquet, and therefore poses an especially difficult
problem. In the study by Kelly and colleagues,4 20% of deaths from hemorrhage
occurred from injuries to these junctional zones. Again, in these early studies from
thewar,NCTHwasnotexplicitlydefinedbutencompasseddisruptionofanytorso-
associatedvascularstructureorviscera.
It is interesting that these figures remained unchanged when Eastridge and
colleagues6expandedthisanalysistoallUSmilitarypersonnelwhodiedofwounds
between2001and2009.Whilelethalheadinjurywasthedominantpatternoftrauma
inthenonsurvivablecases,hemorrhageagainaccountedfor80%ofpotentiallysurviv-
abledeaths.Truncalhemorrhageaccountedfor48%ofdeathsinthiscohortofcasu-
alties. The publication of these studies provided an important characterization of
battlefieldinjury,andillustratedthehighandearlylethalityofNCTHinthosewhocould
haveotherwisesurvivedtheirinjuries.Inparallelwithpostmortemstudies,severalclin-
icalstudieshaveexaminedtheincidenceofhemorrhageinparticularorgansystems.
In a study using the US Joint Theater Trauma Registry (JTTR), White and
colleagues9 reported the incidence of vascular injury in US troops between 2002
and2009.Theinvestigatorsobservedaspecificvascularinjuryrateof12%(1570of
13,075), which was 5 times higher than that described in previous wartime reports.
Named large vessel injury accounted for 12% of the torso vascular injuries in this
study,withiliac,aortic,andsubclavianvesselsbeingthemostcommonlyinjured.
In a separate study also using the JTTR, Propper and colleagues10 examined
wartimethoracicinjuryfrom2002to2009.Theinvestigatorsfoundthatthoracicinjury
ofanytypeoccurredin5%ofwartimecasualties.Inthiscohort,meanInjurySeverity
Score(ISS)was15andcrudemortalitywas12%.Themostcommonthoracicinjury
patterninthisstudywaspulmonarycontusion(32%),followedbyhemopneumothorax
(19%).
NoncompressibleTorsoHemorrhage 847
A report by Morrison and colleagues11 from a single combat support hospital in
Afghanistan analyzed 12 months of consecutive episodes of abdominal trauma.
Morethanhalf(65patients,52.0%)requiredimmediatelaparotomy,withhemorrhage
from solid organs identified in 46 patients (70.8%). There were 15 deaths (23%) in
patientsundergoingimmediatelaparotomy,withamedianNewISSof29andrange
of1to67.
Despitethevalueofthesestudies,theydonotspecificallyemphasizethepotential
lethalityfromvasculardisruptionresultinginNCTH.Inthiscontextandgiventheunde-
niable association of NCTH with early mortality in those with otherwise survivable
injuries, military researchers and civilian collaborators have aggressively sought to
establishaunifyingdefinitionofthisinjurypattern.Table1showstheinitialdefinition
ofNCTHdevelopedattheUSArmy’sInstituteofSurgicalResearch,whichisbasedon
thepreviouslymentionedanatomiccategoriesofvasculardisruptionlinkedtoeither
a physiologic or procedural criterion. A procedure in this definition is defined as an
emergent laparotomy, thoracotomy, or procedure undertaken to control bleeding
fromacomplexpelvicinjury.
EPIDEMIOLOGYOFNONCOMPRESSIBLETORSOHEMORRHAGE
ArecentstudyoftheUSJTTRpresentedattheAmericanAssociationfortheSurgery
ofTraumain2011usedthedefinitionpresentedinTable1tocharacterizetheepide-
miologyofNCTHinpatientsinjuredinIraqandAfghanistanbetween2002and2010.
Usingtheinjurypatterncriteriaalone,1936patientswereidentifiedashavinganinjury
putting them at risk for NCTH, which was nearly 13% of battle-related casualties.
When the physiologic and procedural inclusion criteria were applied to this cohort,
331patientswithameanISS(cid:4)SDof30(cid:4)13wereidentifiedashavingNCTH.The
most common pattern of hemorrhage was pulmonary parenchyma (32%), followed
bybleedingfromanamed,largevesselwithinthetorso(20%).High-gradesolidorgan
injury(gradeIVorVliver,kidney,orspleen)alsoconstituted20%ofcases,andpelvic
fracture with vascular disruption accounted for 15%. The most lethal injury pattern
(oddsratio;95%confidence interval)inthisstudywasthatto anamedlargevessel
within the torso (3.42; 1.91–6.10), followed by injury to the pulmonary parenchyma
(1.89;1.08–3.33),andcomplexpelvicfracturewithvesseldisruption(0.80;0.36–1.80).
The same investigators applied this definition to British troops injured in Iraq and
Afghanistan from 2001 to 2010 using the United Kingdom’s Trauma Registry. This
analysis included patients who died before receiving treatment at a military surgical
hospital(ie,killedinaction)andthusdidnotapplythephysiologicorproceduralinclu-
sioncriteria.Thisreportidentified234patientswiththeanatomicinjuryprofileatrisk
forNCTH,whichwas13%ofUKbattle-relatedinjuries,anumbernearlyidenticalto
the incidence of this injury pattern in the US JTTR. The overall case fatality rate of
UK patients with NCTH was 83%, compared with 25% for any battle-related injury,
underscoring the significant mortality burden posed by vascular disruption of any
typewithinthetorso.
ThecivilianexperiencewithNCTHcarriesasimilarmessage,albeitwithadifferent
injurypattern.Specifically,vascularinjuryordisruptionwithinthetorsointhecivilian
populationconsistspredominantlyofbluntratherthanpenetratingorexplosivemech-
anisms.2 Hemorrhage remains the leading cause of potentially preventable death in
civilian settings, accounting for 30% to 40% of mortality, with 33% to 56% of such
deathsoccurringintheprehospitalphaseofinjury.1Tienandcolleagues12examined
558consecutivetraumadeathsataCanadianlevel-Itraumacenter.Whilethemost
numerous cause of death was related to central nervous system injury, 15% were
848 Morrison&Rasmussen
duetohemorrhage,with16%ofsuchdeathsjudgedtobepreventable.Delayiniden-
tifyingthebleedingsourcewascitedasthemostcommonpreventablereason,with
pelvic hemorrhage the most common source. These findings were confirmed and
extendedbyinvestigatorsatLosAngelesCounty1UniversityofSouthernCalifornia
Medical Center, which identified delayed pelvic hemorrhage control as the most
frequentcauseofpreventabledeathsfromhemorrhage.13
CLINICALMANAGEMENTSTRATEGIESINTORSOHEMORRHAGECONTROL
Theaimofthissectionistoprovideasummaryoftoolsandadjunctsavailableforthe
controloftorsohemorrhagewithinthecontextofcurrentliterature.Despiteadvances
insurgicalunderstanding,technique,andtechnology,onefundamentaltenetremains:
proximalanddistalcontrolareessentialwhenmanagingsuspectedvascularinjury.
Damage-ControlSurgeryandDamage-ControlResuscitation
Damage-controlsurgery(DCS)isasurgicalstrategyoriginallydescribedinthecontext
ofexsanguinatingabdominaltrauma,wherebythecompletenessofoperativerepairis
sacrificedtolimitphysiologicdeterioration.14,15Thistechniquehasbeenextendedto
includeotherbodyregions.16Definitiveoperativerepairisthencompletedinastaged
fashion following resuscitation and warming in the intensive care unit. DCS is an
extreme surgical strategy that carries a risk of infection; intra-abdominal abscess,
wounddehiscence,incisionalhernia,andenterocutaneousfistulasarecommon.17–19
Consequently,thisapproachshouldonlybeusedinselectpatients,asdiscussedin
thereviewbyChovanesandcolleagueselsewhereinthisissue.
MilitaryexperienceinIraqidentifiedasurvivalbenefitinpatientsreceivingahigher
ratioofpackedredbloodcells(PRBC)tofreshfrozenplasma(FFP),whohadasignif-
icantlylowermortalitythanpatientsreceivingthelowerratio(19%vs65%;P<.001).20
Thisfindinghasbroughtabouttheconceptofabalancedorhemostaticresuscitation
wherebymajortraumapatientsareresuscitatedwithaunitratioofaround1:1PRBCto
FFP. This concept has evolved into a coherent strategy incorporating additional
hemorrhage-control adjuncts and is termed damage-control resuscitation (DCR).21
MostDCRprotocolsincorporatetechniquessuchaspermissivehypotension,minimal
useofcrystalloid,aggressivewarming,andnovelinfusiblehemostaticdrugssuchas
tranexamicacid,pairedwithDCSforearlyhemorrhagecontrol.22
ItisimportantthatDCSshouldbeconsideredatoolwithinDCR,whichmaybeused
incircumstancesofextreme physiologyorsignificantanatomicinjuryburden.23The
evidence thus far suggests that the adoption of DCR confers a survival advantage,
andisassociatedwithareductionintheuseofDCStechniques.18,24,25Thespecific
elementsofDCRarewellreviewedbyCohenelsewhereinthisissue.
However, although DCR demonstrates significant promise, it does liberally use
precious resources exposing patients to the risks associated with blood products.
Workisbeingundertakenonproductratios26,27andtheuseofnovelcompoundsto
reducethisreliance,suchaslyophilizedfibrinogenandplatelets.28
ResuscitativeSurgicalManeuvers
AproportionofpatientswithNCTHpresentwithcirculatorycollapse,eitherprofoundly
hypotensiveorincardiacarrest.Managementofpatientspresentinginsuchafashion
hasbeenextensivelystudied.29–32Thecurrentcivilianstandardofcareistoperform
aresuscitativethoracotomy(RT),whichpermitsthefollowingmaneuvers33:
(cid:1) Releaseofcardiactamponade
(cid:1) Managementofthoracicbleeding
NoncompressibleTorsoHemorrhage 849
(cid:1) Controlofmassiveair-leaks
(cid:1) Internalcardiacmassage
(cid:1) Thoracicaorticocclusion.
Thelattermaneuverisundoubtedlythemostpracticed,asaorticcontroltheoreti-
callyenhancescerebralandmyocardialperfusion.
AlthoughRTistypicallyperformedforthoracicwounding,ithasbeenexploredfor
useinpatientswithatensehemoperitoneuminphysiologicdistress.34,35Theaimisto
obtaincontrolofthevascularinflowoftheabdomenwhileenhancingcentralpressure,
beforelaparotomyandabdominalhemostasis.Thisapproachisnowbeingchallenged
becauseofitspoorsurvivalrate,althoughthephysiologicprincipleofaorticocclusion
supportingcentralpressureremains.
Resuscitative techniques whereby proximal control is remote to the site of injury
should not be used liberally, as direct vascular control, when possible, results in
alesserischemicburden.Arecentanimalstudyexaminedthoracicclampingversus
aorticclampingversusdirectcontrolofaniliacarterialinjuryidentifiedasignificantly
reducedburdenofglobalischemiawithdirectcontrol.36
Aortic occlusion can also be achieved by endovascular balloon occlusion, as
demonstratedbytheuseofpercutaneousdevicesusedtocontroltheneckofabdom-
inal aortic aneurysms during endovascular repair.37,38 This technique enables the
physiologic benefit to be realized without the additional burden of entering a body
cavity.SuchatechniquehasbeenusedintraumaasearlyastheKoreanWar39and
since.40To date, it has notbeenused widely orsystematically evaluated. However,
withrecentimprovementsinendovasculardevicesandresuscitationingeneral,there
isarenewedinterestinthisapproach,whichhasbeentermedresuscitativeendovas-
cularballoonocclusionoftheaorta(REBOA).41
RecentanimalworkhascharacterizedthereducedphysiologicburdenofREBOA
compared with RT.42 Animals in class IV shock were allocated to aortic occlusion
by a balloon or clamp via thoracotomy. The balloon group demonstrated the same
improvement in mean aortic pressure as the clamp group, but with a lower lactate,
baseexcess,andpHmeasurementsafterintervention.Adifferentgrouphasidentified
40minutesastheoptimumtimeforaorticballoonocclusioninhypovolemicanimals
usingsimilarendpoints.43
OperativeExposuresinNoncompressibleTorsoHemorrhage
The majority of patients with these types of injuries qualify for management in
adamage-controlfashion,andtheappropriatesurgicalmaneuversdependsprimarily
onthelocationofhemorrhagewithinthetorso.Certaintechniquesaredescribedwell
byChovanesandcolleaguesinthisissue.
Thorax
Forhemorrhagecontrolwithinthethoraciccavity,accesstotheipsilateralsideisbest
viaananterolateralthoracotomy,throughthefourthinterspace,withthepatientinthe
supineposition,tilteduponaroll(Fig.2).Thisapproachalsoallowsextensionofthis
incisionacrossthesternumintotherighthemithoraxortheclam-shellincision,permit-
ting access to either of the other 2 compartments in the chest (mediastinum and
contralateralthoraciccavity)ifrequired(Fig.3).Itisimportantthatasurgeonperform-
ingthismaneuvermustalsohavetheabilitytoconcomitantlyexploretheabdomen,so
thismustbeincludedwhenpreparingthesurgicalfield.
Oncewithinthechest,hemorrhagecontrolisthepriority.Pulmonarybleedingcan
becontrolledusingseveraltechniques,dependingonlocation.Injurytotheperiphery
850 Morrison&Rasmussen
Fig.2. Anterolateralthoracotomythroughthefourthintercostalspacepermittingaccessto
the left hemithorax, aorta, and cardiac structures. (From Hirshberg A, Mattox KL. The
nononsensetraumathoracotomy.In:Topknife.Shrewsbury:TFMPublishingLtd;2005.p.
160.(cid:1)January2005,AsherHirshbergMD&KennethL.MattoxMD;withpermissionfrom
TFMPublishingLtd.[www.tfmpublishing.com]).
ofthelungcanbestapledoffinanonanatomicfashionusingalinearstapler.Bleeding
fromwithinawoundtractiseffectivelymanagedfollowingtractotomy,wherebyalinear
staplerorclampisintroduceddownthelengthofthewoundtractandthendeployed.
This action opens the tract, permitting direct oversewing of disrupted vessels using
3-0or4-0polypropylenesuturesonalargertaperedneedle(eg,SH)orcontrolwith
astaplingdevice.
Ifhemorrhagefromthelungisfromthedeeperhilarstructures,thelungitself(after
mobilization)canbecompressedoreventwistedonitselftooccludethehilarvessel.
Fig.3. Extensionoftheanterolateralthoracotomyacrossthesternumintotherightintercostal
space, facilitating access to the mediastinum and right hemithorax. (From Hirshberg A,
MattoxKL.Thenononsensetraumathoracotomy.In:Topknife.Shrewsbury:TFMPublishing
Ltd; 2005. p. 161. (cid:1) January 2005, Asher Hirshberg MD & Kenneth L. Mattox MD; with
permissionfromTFMPublishingLtd.[www.tfmpublishing.com]).
NoncompressibleTorsoHemorrhage 851
Because such a hilar twist results in a physiologic burden similar to a pneumonec-
tomy (ie, significant elevation in right heart afterload), it should be performed only
as a last resort. In cases where the injury significantly compromises a patient’s
pulmonary reserve, extracorporeal life support (ECLS) may also be a useful
adjunct.44
Abdomen
Theabdomenshouldbeopenedthroughamidlineincisionfromthexiphoidprocess
tothepubicsymphysistopermitaccesstoall4quadrants.Initialpackingremainsthe
bestmethodofinitialhemostasis,allowingfortheresuscitationtorestorethecircu-
lating volume. An additional useful adjunct for patients in extremis is resuscitative
aorticocclusionoftheaortaatthediaphragmatichiatus.Thenextkeystepissequen-
tialevaluationoftheabdomenandadecisionregardinglocalcontrolofhemorrhage
andcontamination.
Hemorrhagefromthesolidorgansoftheabdomenismanageddifferently,depend-
ingontheorganinquestion.Exposureandremovalofthespleenisfairlystraightfor-
wardandwelltoleratedbythepatient,andthussplenectomyisthefavoredmaneuver
forthehemorrhagingspleen.
By contrast, hemorrhage from the liver necessitates packing to control venous
bleeding in most instances. Control of the porta hepatus at the gastrohepatic liga-
ment and application of the Pringle maneuver is often used as an adjunct to liver
packing to control inflow to the organ. Depending on the nature of the wound and
thelocationofthehepaticbleeding,thelivercanbemobilizedbydividingthecoro-
nary and triangular ligaments and allowing the left and right lobes to be drawn or
compressed together. If this maneuver is successful, a Vicryl mesh can be used to
wraptheliverandmaintainappositionofthelobesforhemostasis.Ifthebleedingliver
woundisadefinedtract,atractotomycanbeperformedtoallowexposureandliga-
tionofspecificvesselsdeeperwithinthewound,oraPenrosedraincanbetiedover
anasogastrictubetoallowinflationofthePenrosewithinthetractandapplicationof
aballoontamponade.
MesentericvesselscanbecontrolledbyForgartythrombectomyballoons,inserted
proximallythroughsmalltomid-sizedvesselsandinflatedforproximalcontrolinsome
cases.Collateralflowtothebowelisgenerallyrobust,andligationofbranchesofthe
superiormesentericarterydistaltothemiddlecolicarteryisoftentolerated.Similarly,
proximalbranchesoftheceliacarteryorthearteryitselfcanbeligatedasadamage-
control maneuver with serial observation of the bowel. If the superior and inferior
mesenteric and internal iliac arteries are patent and uninjured, ligation of proximal
celiacarterybranchesortheceliacarteryitselfisoftentolerated.Althoughtemporary
vascularshuntsaremainlyusedinextremityvessels,therearecasereportsoftheir
applicationtomesentericvesselinjuries.45
Retroperitoneum
Posteriortotheperitonealsacliestheretroperitoneum, whichcanbedivided into4
zones. Zone I is centrally located and contains the aorta and inferior vena cava
(IVC). Hemorrhage often manifests as a hematoma and should always be explored
in this zone. Management of such injuries should adhere to standard principles of
proximal and distal control of the vessel. The aorta can be widely exposed through
aleftmedialvisceralrotation(theMattoxmaneuver,Fig.4)bymobilizingtheleftcolon
and kidney. The IVC can be explored through a right visceral rotation (the Cattel-
Braasch maneuver, Fig. 5), mobilizing the large and small bowel fully to the root of
themesentery.