INTRODUCTION AND SITUATIONAL AWARENESS
Military vascular injury management differs significantly from the management of civilian traumatic injuries with respect to three distinct variables: mechanism of injury, care within an echeloned trauma system, and delivery of care within an austere and frequently resource-constrained environment with potentially hostile tactical threats. All three of these variables, both individually and collectively, may significantly alter how vascular injuries are triaged, diagnosed, and managed both in the short term (hours) and over the following weeks and months post injury. The focus of this chapter is to aid general as well as vascular surgeons who work in or are preparing to deploy to these types of austere settings in the evaluation and optimal management of these injuries.
Contemporary multi-national doctrine (United States and United Kingdom) focuses on an integrated health system to triage, treat, evacuate if necessary, and return the warfighter to duty in the most efficient manner possible. The injured patient will typically proceed from the point of injury through multiple echelons of care commonly referred to as “Roles.” Role 1 care is generally unit level care provided by combat medics at the point of injury, and role 2 care is designated medical units that may offer purely medical care (aid station) or may have damage control surgery capabilities (Forward Surgical Team or similar). Role 3 is more robust hospital units with advanced surgical and intensive care capabilities, and Roles 4 and 5 care typically involve tertiary or quaternary care facilities located outside of the theater of operations or in the home county.1 Although in traditional doctrine all patients would proceed through each of these roles of care, the nature of modern lower-level or asymmetric warfare that lacks standard “front-lines” has somewhat disrupted this concept and select patients may frequently bypass one or more roles, depending on the local assets and military layout. However, careful attention is always paid to maintaining an orderly chain of care and evacuation system. The rationale for this is to provide aggressive forward hemorrhage control resuscitation, damage control surgery, and stabilization prior to subsequent movement between facilities. The vascular capabilities at each role vary but generally become more sophisticated with increasing roles of care. Table 25-1 outlines the capabilities at each role facility. Perhaps the key difference in military injury management versus civilian trauma management remains the concept of timely evacuation through the military trauma system echelons (aka Roles of care). Unlike a civilian trauma system, many surgeons or providers distributed across multiple military medical treatment facilities (MTFs) may assist in the management of a vascular injury, from placement of shunt in a Role 2 facility versus definitive revascularization in a Role 3 or higher facility. It is also important to note that these concepts mainly apply to the U.S./U.K. or NATO allied forces who are wounded or injured in a combat zone. Injured host national patients usually cannot be evacuated out of theater or even transferred between facilities, ...