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DOI: 10.1055/a-0713-0833
Management von Gefäßverletzungen bei militärischen Konflikten und Terroranschlägen
Management of Vascular Trauma in Military Conflicts and Terrorist AttacksPublication History
Publication Date:
24 October 2018 (online)
![](https://www.thieme-connect.de/media/zblchir/201805/lookinside/thumbnails/10-1055-a-0713-0833_zbc1463-1.jpg)
Zusammenfassung
Im Krieg und bei Terroranschlägen erleiden bis zu 12% aller Verwundeten schwere Gefäßverletzungen. Die Entwicklungen in der Gefäßtraumatologie sind daher eng mit den bewaffneten Konflikten des 20. und 21. Jahrhunderts verknüpft. In diesem Beitrag werden anhand der historischen Erfahrungen militärchirurgische Aspekte bei Gefäßverletzungen diskutiert und die aktuellen Standards der Militärchirurgie auf diesem Gebiet dargestellt. Während bis einschließlich zum Zweiten Weltkrieg verletzte Gefäße überwiegend ligiert werden mussten, konnte erstmals im Korea- und Vietnamkrieg ein hoher Anteil der Gefäßverletzungen erfolgreich rekonstruiert werden. Zusammen mit der verbesserten Evakuierung durch Einsatz von Hubschraubern führte dies zu einer Reduzierung der Amputationsrate von fast 50% auf unter 15%. Nach wie vor ist jedoch das Verbluten die Hauptursache vermeidbarer Todesfälle auf dem Schachtfeld. Die standardmäßige Einführung von Tourniquets, Hämostyptika und Ballonokklusion der Aorta haben die Überlebenschancen verbessert. Das Damage-Control-Prinzip ist insbesondere bei Forward Surgical Teams unverzichtbar und der temporäre intravasale Shunt hat sich frontnah als gefäßchirurgische Damage-Control-Maßnahme längst durchgesetzt. Aufwendige Ausbildungskonzepte vieler Streitkräfte sichern die gefäßchirurgische Notfallkompetenz der stationierten Militärchirurgen. Die Militärchirurgie verfügt aus Krisen- und Kriegsgebieten über reichlich Erfahrung in der Versorgung von massiven Blutungen und schweren Gefäßverletzungen. Zahlreiche hierbei gewonnene Erkenntnisse und Techniken wurden im Laufe der Zeit in die zivile Chirurgie übernommen und aktuelle militärische Entwicklungen beeinflussen auch heute noch die zivile Traumaversorgung.
Abstract
In war and terror attacks, up to 12% of all casualties suffer a severe vascular injury. Therefore, management of vascular trauma is closely associated with lessons learned during the wars of the 20th and 21st century. This article discusses military aspects of vascular trauma based on historical developments and introduces current standards in military vascular surgery. Up to Word War II, ligation was the predominant therapy for severe vascular trauma. Beginning in the Korean and Vietnam Wars, arterial reconstruction became more and more feasible. This development – in conjunction with rapid helicopter evacuation – decreased the former amputation rate of almost 50% to less than 15%. Nevertheless, exsanguination still remains the major cause of death among casualties with potentially survivable injuries. Standard application of tourniquets, haemostyptica, and balloon occlusion of the aorta improved survival rate. Meanwhile, damage control principals are essential for Forward Surgical Teams and the use of temporary intravascular shunts is well implemented in combat settings. In many armed forces, sophisticated training programs ensure the necessary competence in vascular surgery for all military surgeons deployed. Military surgery provided ample evidence and experience in the management of major vascular trauma over the last century. Much of this knowledge has been translated to civilian health providers and ongoing developments in the military still influence the management of severe vascular trauma.
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Literatur
- 1 Rich NM. Historical and military Aspects of vascular Trauma. In: Rich NM, Mattox KL, Hirshberg A. Vascular Trauma. 2nd ed.. Philadelphia, USA: Elsevier Saunders; 2004: 3-72
- 2 White JM, Stannard A, Burkhardt GE. et al. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg 2011; 253: 1184-1189
- 3 Heldenberg E, Givon A, Simon D. et al. Terror attacks increase the risk of vascular injuries. Front Public Health 2014; 2: 1-5
- 4 Soubbotitch V. Military experiences of traumatic aneurysms. Lancet 1913; 182: 720-721
- 5 Makins GH. Gunshot Injuries of the Blood Vessels. Bristol, England: John Wright & Sons; 1919
- 6 DeBakey ME, Simeone FA. Battle injuries of the arteries in World War II: an analysis of 2471 cases. Ann Surg 1946; 123: 534-579
- 7 Jahnke jr. EJ, Seeley SF. Acute vascular injuries in the Korea War: an analysis of 77 consecutive cases. Ann Surg 1953; 138: 158-177
- 8 Inui FK, Shannon J, Howard JM. Arterial injuries in the Korean Conflict: experiences with 111 consecutive injuries. Surgery 1953; 37: 850-857
- 9 Hughes CW. Acute vascular trauma in Korean War casualties: an analysis of 180 cases. Surg Gynecol Obstet 1954; 99: 91-100
- 10 Hughes CW. The primary repair of wounds of major arteries: an analysis of experience in Korea in 1953. Ann Surg 1955; 141: 297-303
- 11 Hughes CW. Arterial repair during the Korean War. Ann Surg 1958; 147: 555-561
- 12 Rich NM, Hughes CW. Vietnam vascular registry: a preliminary report. Surgery 1969; 65: 218-226
- 13 Rich NM, Baugh JH, Hughes CW. Acute arterial injuries in Vietnam: 1000 cases. J Trauma 1970; 10: 359-369
- 14 Rich NM, Hughes CW, Baugh JH. Management of venous injuries. Ann Surg 1970; 171: 724-730
- 15 Rich NM, Hobson RW, Collins jr. GJ. et al. The effect of acute popliteal venous interruption. Ann Surg 1976; 183: 365-368
- 16 Gifford SM, Aidinian G, Clouse EWD. et al. Effect of temporary shunting on extremity vascular injury: an outcome analysis from the Global War on Terror vascular injury initiative. J Vasc Surg 2009; 50: 549-555
- 17 Billy LJ, Amato JJ, Rich NM. Aortic injuries in Vietnam. Surgery 1971; 70: 385-391
- 18 Cohen CA, Brief D, Mathewson C. Carotid artery injuries. An analysis of eighty-five cases. Am J Surg 1970; 120: 210-214
- 19 Fox CJ, Gillespie DL, OʼDonnell SD. et al. Contemporary management of wartime vascular trauma. J Vasc Surg 2005; 41: 638-644
- 20 Roccaforte JD. The World Trade Center Attack. Observations from New Yorkʼs Bellevue Hospital. Crit Care 2001; 5: 307-309
- 21 Biddinger PD, Baggish A, Harrington L. et al. Be prepared – The Boston Marathon and mass-casualty events. N Engl J Med 2013; 368: 1958-1960
- 22 De Ceballos JP, Turégano-Fuentes F, Pérez-Díaz D. et al. 11 March 2004: The terrorist bomb explosions in Madrid, Spain – an analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest hospital. Crit Care 2005; 9: 104-111
- 23 Tresson P, Touma J, Gaudric J. et al. Management of vascular trauma during the Paris terrorist attack of November 13, 2015. Ann Vasc Surg 2017; 40: 44-49
- 24 Gaarder C, Jorgensen J, Kolstadbraaten KM. et al. The twin terrorist attacks in Norway on July 22, 2011: the trauma center response. J Trauma Acute Care Surg 2012; 73: 269-275
- 25 Aylwin CJ, König TC, Brennan NW. et al. Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet 2006; 368: 2219-2225
- 26 King DR, Larentzakis A, Ramly EP. et al. Tourniquet use at the Boston Marathon bombing: Lost in translation. J Trauma Acute Care Surg 2015; 78: 594-599
- 27 Eastridge BJ, Mabry RL, Seguin P. et al. Death on the battlefield (2001–2011): implications for the future of combat casualty care. J Trauma Acute Care Surg 2012; 73: S431-S437
- 28 Butler jr. FK, Hagmann J, Butler EG. Tactical combat casualty care in special operations. Mil Med 1996; 161 (Suppl.) S3-S16
- 29 Beekley AC, Sebesta JA, Blackbourne LH. et al. Prehospital tourniquet use in Operation Iraqi Freedom: effect of hemorrhage control and outcomes. J Trauma 2008; 64: S28-S37
- 30 Bulger EM, Snyder D, Schoelles K. et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care 2014; 18: 163-173
- 31 Passos E, Dingley B, Smith A. et al. Tourniquet use for peripheral vascular injuries in the civilian setting. Injury 2014; 45: 573-577
- 32 Kragh jr. JF, Walters TJ, Baer DG. et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg 2009; 249: 1-7
- 33 Kragh jr. JF, Dubick MA, Aden JK. et al. U.S. Military use of tourniquets from 2001 to 2010. Prehosp Emerg Care 2015; 19: 184-190
- 34 Lakstein D, Blumenfeld A, Sokolov T. et al. Tourniquets for hemorrhage control on the battlefield: A 4-year accumulated experience. J Trauma 2003; 54: S221-S225
- 35 DuBose JJ, Savage SA, Fabian TC. et al. The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry: multicenter data on modern vascular injury diagnosis, management and outcomes. J Trauma Acute Care Surg 2015; 78: 215-222
- 36 Leonard J, Zietlow J, Morris D. et al. A multi-institutional study of hemostatic gauze and tourniquets in rural civilian trauma. J Trauma Acute Care Surg 2016; 81: 441-444
- 37 Shlaifer A, Yitzhak A, Baruch EN. et al. Point of injury tourniquet application during Operation Protective Edge – What do we learn?. J Trauma Acute Care Surg 2017; 83: 278-283
- 38 Ode G, Studnek J, Seymour R. et al. Emergency tourniquets for civilians: Can military lessons in extremity hemorrhage be translated?. J Trauma Acute Care Surg 2015; 79: 586-591
- 39 Deutsche Gesellschaft für Unfallchirurgie e.V.. Hrsg. S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung. AWMF Register-Nr. 012/019, 2016. Im Internet: https://www.awmf.org/uploads/tx_szleitlinien/012-019l_S3_Polytrauma_Schwerverletzten-Behandlung_2017-08.pdf Stand: 18.06.2018
- 40 Kelly JF, Ritenour AE, McLaughlin DF. et al. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003–2004 versus 2006. J Trauma 2008; 64: S21
- 41 Hinck D, Wipper S, Debus ES. Hämostyptika zur Behandlung der „junctional vascular injuries“ – Versorgung traumatischer Gefäßverletzungen am Übergang vom Körperstamm zur Extremität. Unfallchirurg 2018; 121: 530-536
- 42 DʼAlleyrand JCG, Dutton RP, Pollak AN. Extrapolation of battlefield resuscitative care to the civilian setting. J Surg Orthop Adv 2010; 19: 62-69
- 43 Hughes CW. Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man. Surgery 1954; 36: 65
- 44 Brenner M, Teeter W, Hoehn M. et al. Use of resuscitative endovascular balloon occlusion of the aorta for proximal aortic control in patients with severe hemorrhage and arrest. JAMA Surg 2018; 153: 130-135
- 45 Manley JD, Mitchell BJ, DuBose JJ. et al. A modern case series of resuscitative endovascular balloon occlusion of the aorta (REBOA) in an out-of-hospital, combat casualty care setting. J Spec Oper Med 2017; 17: 1-8
- 46 Rasmussen TE, Eliason JL. Military-civilian partnership in device innovation: development, commercialization and application of resuscitative endovascular balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg 2017; 83: 732-735
- 47 White JM, Cannon JW, Stannard A. et al. Endovascular balloon occlusion of the aorta is superior to resuscitative thoracotomy with aortic clamping in a porcine model of hemorrhagic shock. Surgery 2011; 150: 400-409
- 48 Kulla M, Engelhardt M, Holsträter T. et al. REBOA als alternatives Konzept zur Notthorakotomie bei Schwerverletzten – notwendig oder entbehrlich? Eine Sekundärdatenanalyse aus dem TraumaRegister DGU® . Anästh Intensivmed 2018; 59 : in press
- 49 DuBose JJ, Scalea TM, Brenner M. et al. The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg 2016; 81: 409-419
- 50 Brenner M, Inaba K, Aiolfi A. et al. Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy in selected patients with hemorrhagic shock: early results from the American Association for the Surgery of Traumaʼs Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry. J Am Coll Surg 2018; 226: 730-740
- 51 Elias K, Engelhardt M. “Resuscitative endovascular balloon occlusion of the aorta”. Überbrückende Maßnahme bis zur operativen Versorgung. Unfallchirurg 2018; 121: 537-543
- 52 Russo RM, Williams TK, Grayson JK. et al. Extending the golden hour: Partial resuscitative endovascular balloon occlusion of the aorta in a highly lethal swine liver injury model. J Trauma Acute Care Surg 2016; 80: 372-380
- 53 Engelhardt M, Hinck DC. Damage Control bei Gefäßverletzungen. In: Debus E, Gross-Fengels W. Hrsg. Operative und interventionelle Gefäßmedizin. 2. Aufl. [im Druck]. Berlin, Heidelberg: Springer; 2018
- 54 Ferrada P, Anand RJ, Aboutanos M. et al. Catheter-based endovascular damage-control (CDET): current status and future directions. World J Surg 2014; 38: 330-334
- 55 Taller J, Kamdar JP, Greene JA. et al. Temporary vascular shunts as initial treatment of proximal extremity vascular injuries during combat operations: the new standard of care at echelon II facilities?. J Trauma 2008; 65: 595-603
- 56 Rasmussen TE, Clouse WD, Jenkins DH. et al. The use of temporary vascular shunts as a damage control adjunct in the management of wartime vascular injury. J Trauma 2006; 61: 8-15
- 57 Ball CG, Kirkpatrick AW, Rajani RR. et al. Temporary intravascular shunts: when are we really using them according to the NTDB?. Am Surg 2009; 75: 605-607
- 58 Subramanian A, Vercruysse G, Dente C. et al. A decadeʼs experience with temporary intravascular shunts at a civilian level I trauma center. J Trauma 2008; 65: 316-326
- 59 Oliver JC, Gill H, Nicol AJ. Temporary vascular shunting in vascular trauma: a 10-year review from a civilian trauma centre. S Afr J Surg 2013; 51: 6-10
- 60 Eardley WGP, Taylor DM, Parker PJ. Training tomorrowʼs military surgeons: lessons from the past and challenges for the future. J R Army Med Corps 2009; 155: 249-252
- 61 Mathieu L, Joly B, Bonnet S. et al. Modern teaching of military surgery: why and how to prepare the orthopaedic surgeons before deployment? The French experience. Int Orthop 2015; 39: 1887-1893
- 62 Tyler JA, Ritchie JD, Leas ML. et al. Combat readiness for the modern military surgeon: data from a decade of combat operations. J Trauma Acute Care Surg 2012; 73: S64-S70
- 63 Engelhardt M, Elias K, Friemert B. et al. Gefäßchirurgisches Ausbildungskonzept für Militärchirurgen in Deutschland. Unfallchirurg 2018; 121: 544-549