The algorithms contain letters at decision points, and the corresponding paragraphs in the text elaborate on the thought process and cite the pertinent literature. The annotated algorithms are intended to (a) serve as a quick bedside reference for clinicians, (b) foster more detailed patient care protocols that will allow for prospective data collection and analysis to identify best practices, and (c) generate research projects to answer specific questions concerning decision making in the management of adults with abdominal vascular injuries.
Injuries to the abdominal vessels are caused by penetrating wounds in 90% to 95% of patients. When reviewing series of US military vascular injuries from World War II, the Korean War, and the Vietnam War, the incidence of abdominal vascular injuries was 2%, 2.3%, and 2.9%, respectively.10–1210–1210–12 This reflects the high kinetic energy of military weapons and the delays in transport to definitive care. The incidence of only 2.4% in one report from the recent Iraqi War is presumably a reflection of the body armor worn by US military personnel in the field.13
Civilian trauma centers in the United States treat much higher numbers of patients with abdominal vascular wounds as compared with facilities in combat zones. This is a reflection of the lower wounding power of civilian weapons and the lack of body armor. In one review of patients undergoing laparotomies after sustaining gunshot wounds of the abdomen at Ben Taub General Hospital in Houston in 1988, 24.6% of patients had an injury to a named abdominal vessel.14
Abdominal vessels are described based on a modification of the Zone I (midline retroperitoneum), Zone 2 (upper lateral retroperitoneum), and Zone 3 (pelvic retroperitoneum) classification used in many trauma textbooks. This modification divides Zone I into supramesocolic and inframesocolic areas as well as adding an area encompassing the portal vein and the retrohepatic vena cava.
The hemodynamic status of a patient with an abdominal vascular injury depends on whether a partially or completely contained hematoma or active hemorrhage is present.15,1615,16 When a completely contained hematoma is present, the patient may have only modest hypotension on arrival in the emergency department. This is particularly true if an abdominal venous rather than an abdominal arterial injury is present. Such a patient will be a “responder” to the infusion of crystalloid solutions and blood, and the hypotension may not recur till the hematoma is opened at the time of laparotomy.
When hemorrhage from a vascular injury is occurring through a perforation in the retroperitoneum or directly into the peritoneal cavity upon the patient’s arrival in the emergency department, the patient is hypotensive and a “nonresponder.” This is particularly true if an arterial injury is present. Some of these patients may have a distended abdomen, as well.
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