Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 123-125

Complex vascular injury in a case of multiple gunshot wounds in a combat zone


1 Department of Vascular and Endovascular Surgery, Army Hospital (R&R) Delhi Cantt, New Delhi, India
2 Department of Anesthesiology, Military Hospital, Allahabad, Uttar Pradesh, India
3 Department of Reconstructive Surgery, Army Hospital (R&R) Delhi Cantt, New Delhi, India
4 Department of Vascular and Endovascular Surgery, Sir Ganga Ram Hospital, New Delhi, India

Date of Web Publication3-May-2018

Correspondence Address:
Dr. Vivek Agrawal
Department of Vascular and Endovascular Surgery, Army Hospital (R&R) Delhi Cantt, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_67_17

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  Abstract 


Abdominal vascular injuries are the most common cause of early death after penetrating abdominal trauma if especially associated with a chest injury and fracture of long bones. The surgical exposure and associated intraabdominal injuries may challenge the skills and judgment of even the most experienced surgeons. Rapid transportation to a trauma center, early recognition of injuries, damage control resuscitation, and early surgical intervention are critical for patient's survival.

Keywords: Gunshot, penetrating abdominal trauma, vascular injury


How to cite this article:
Agrawal V, Singh D, Mehrotra S, Bedi V. Complex vascular injury in a case of multiple gunshot wounds in a combat zone. Indian J Vasc Endovasc Surg 2018;5:123-5

How to cite this URL:
Agrawal V, Singh D, Mehrotra S, Bedi V. Complex vascular injury in a case of multiple gunshot wounds in a combat zone. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2021 Nov 29];5:123-5. Available from: https://www.indjvascsurg.org/text.asp?2018/5/2/123/231851




  Introduction Top


Penetrating trauma is responsible for most abdominal vascular injuries and accounts for about 90% of cases in urban as well combat zone trauma centers.[1] In most patients with penetrating abdominal vascular injuries, no investigations are possible because most of them are received in a state of hemorrhagic shock, and there is a need for urgent exploration to find the bleeding vessel. The most important factor for the survival of salvageable patients with vascular injuries is rapid transportation to a trauma center followed by immediate surgical control of the bleeding. We present a case of one serving senior police officer of JK police who was shot with seven bullets in close combat in a counterinsurgency area. There were wounds over chest, abdomen, and extremities leading to injuries in the right lung, a Grade V injury to the left kidney, a rent in inferior venacava (IVC), and disruption of descending colon along with comminuted compound fracture of the left femur. The case was successfully managed at a service hospital in Srinagar.


  Case Report Top


A 42 years senior police officer of Jammu and Kashmir police who was shot by militants in closed range combat with seven bullets was brought to the trauma center of our hospital. He had injuries over the right side of chest, abdomen, right upper limb, and both lower limbs. He was bleeding profusely from these sites. One bullet had entered from the right lumbar region with exit wound on the left flank. On presentation, patient was in hemorrhagic shock with the evisceration of omentum from the left flank [Figure 1]. Immediately, patient was shifted to operation theater with ongoing resuscitation. Left internal jugular vein triple lumen 8.5 Fr central venous catheter was inserted immediately for resuscitation. Right ICD was placed and emergency exploratory laparotomy was started. On exploration, he had hemoperitoneum with Grade IV injury to descending colon. There was a retroperitoneal hematoma as well. The hematoma was opened by retracting the transverse colon and small bowel. On exploration, we found that renal vessels were shattered, left kidney had an injury on the lower pole, and there was a rent in IVC probably due to disruption of the left renal vein [Figure 2]. Therefore, left nephrectomy was done, and IVC was repaired primarily. Excision of descending colon with transverse colostomy was done and the mucous fistula was created [Figure 3]. Intraoperatively, fractured transverse process could be felt so there were chances of spinal cord injury that has to be excluded at a later date. The external fixator was applied for compound comminuted fracture of the left femur [Figure 4]. The estimated blood loss was close to 4.5 L. He was infused with 6.5 l of crystalloids and 19 units of blood and blood products intraoperatively and required high doses of vasopressors even to maintain a mean arterial pressure of 60–65 mmHg. Postoperatively, he had to be transfused with 8 units of blood and blood products. He was on a mechanical ventilator for next 2 days. On the 3rd day, he was taken for computerized tomography chest and abdomen which revealed intact spine except fracture of L1 to L4 transverse processes and fracture of the 9th and 10th left ribs [Figure 5]. He had wound infection in the left thigh which was managed with dressing and subsequently with skin grafting. On the postoperative period, he developed pneumonia of left lung which was managed symptomatically. He was discharged to home in walking condition with the help of walker after all his wounds were healed. Intestinal continuity was restored after 3 months laparoscopically. At 1-year follow-up, he is doing fine, walking independently, and has joined office duty.
Figure 1: At arrival – Omentum protruding out of exit wound and dressing in the left thigh

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Figure 2: Disrupted renal pedicle with descending colon injury

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Figure 3: Immediate postoperative picture

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Figure 4: X-ray left thigh showing the left side compound femur fracture

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Figure 5: Computed tomography scan showing fracture of left 2, 3, 4, 5 transverse process and 11th left rib

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  Discussion Top


Abdominal vascular injuries are the most common cause of early death after penetrating abdominal trauma specially associated with chest injury and fracture of long bones. The most important factor for the survival of salvageable patients with vascular injuries is rapid transportation to a trauma center followed by immediate surgical control of the bleeding. A policy of “scoop and run” is currently the recommended approach. The role of prehospital intravenous fluid administration is controversial, with some studies showing improved survival with fluid restriction and others showing no effect on survival.[2],[3] Low-velocity missiles cause direct injury to the vessel, whereas high-velocity missiles and blasts can also cause vascular trauma by means of the shock wave and transient cavitation.

In most patients with penetrating abdominal vascular injuries, no investigations are possible preoperatively due to the patient's critical condition and the obvious need for immediate laparotomy. About 30% of victims with gunshot injuries to the abdomen have multiple gunshot wounds,[4] and an abdominal radiograph may provide useful information. As per Asensio et al. most commonly injured abdominal vessel are the IVC (accounting for 25% of injuries) followed by the aorta (21%), iliac arteries (20%), iliac veins (17%), superior mesenteric vein (11%), and superior mesenteric artery (10%).[1] In patients who undergo exploratory laparotomy for injury, the incidence of vascular trauma is 14.3% for gunshot injuries,[4] 10% for stab wounds,[5] and 3% for blunt injuries.[6]

Permissive hypotension is beneficial and prevents massive exsanguination while avoiding the risk of cardiovascular collapse due to massive blood loss and severe hypotension.[7],[8]

As a general rule, almost all retroperitoneal hematomas due to penetrating trauma should be explored irrespective of size. Underneath a small hematoma, there is often a vascular or hollow viscus perforation as was appreciated in our index case. The inframesocolic zone 1 area can be approached by retracting the transverse colon cephalad and displacing the small bowel to the right which was exactly done in our case.

Many patients with major abdominal vascular injuries require massive blood transfusions and may develop hypothermia, acidosis, and coagulopathy intraoperatively as well as postoperatively. These patients will be benefitted from early damage control and definitive reconstruction at a later stage.


  Conclusion Top


Abdominal vascular injuries are the most common cause of death after penetrating abdominal trauma if especially associated with the chest injury and fracture of long bones. Rapid exsanguination can be fatal. Urgent transportation to a trauma center, early recognition of the injuries, early surgical intervention, excellent knowledge of anatomy, and good surgical judgment are critical for the patient's survival.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Asensio JA, Chahwan S, Hanpeter D, Demetriades D, Forno W, Gambaro E, et al. Operative management and outcome of 302 abdominal vascular injuries. Am J Surg 2000;180:528-33.  Back to cited text no. 1
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2.
Bickell WH, Wall MJ Jr., Pepe PE, Martin RR, Ginger VF, Allen MK, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994;331:1105-9.  Back to cited text no. 2
    
3.
Dutton RP, Mackenzie CF, Scalea TM. Hypotensive resuscitation during active hemorrhage: Impact on in-hospital mortality. J Trauma 2002;52:1141-6.  Back to cited text no. 3
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4.
Demetriades D, Velmahos G, Cornwell E 3rd, Berne TV, Cober S, Bhasin PS, et al. Selective nonoperative management of gunshot wounds of the anterior abdomen. Arch Surg 1997;132:178-83.  Back to cited text no. 4
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5.
Feliciano DV, Burch JM, Graham JM. Abdominal vascular injury. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000. p. 783-806.  Back to cited text no. 5
    
6.
Cox EF. Blunt abdominal trauma. A 5-year analysis of 870 patients requiring celiotomy. Ann Surg 1984;199:467-74.  Back to cited text no. 6
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7.
Stern SA, Dronen SC, Birrer P, Wang X. Effect of blood pressure on hemorrhage volume and survival in a near-fatal hemorrhage model incorporating a vascular injury. Ann Emerg Med 1993;22:155-63.  Back to cited text no. 7
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8.
Leppäniemi A, Soltero R, Burris D, Pikoulis E, Waasdorp C, Ratigan J, et al. Fluid resuscitation in a model of uncontrolled hemorrhage: Too much too early, or too little too late? J Surg Res 1996;63:413-8.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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