PROXIMAL VASCULAR CONTROL

The level of proximal vascular control required to control bleeding is dictated by several factors: associated pelvic disruption, level of tourniquet placement and level of traumatic amputation(s). Typically, vascular control should be achieved at the most distal level possible, including control via a retroperitoneal approach or in the groin. If a laparotomy is performed, walking the clamps down the internal and external iliac arteries in patients with massive pelvic injuries is another excellent technique to control hemorrhage. This technique can be augmented by Zone 3 REBOA with distal aortic occlusion while vascular control is being obtained in the pelvis or groin.19 In cases of pelvic floor injuries with open pelvic wounds and active external posterior bleeding, temporary control of the internal iliac arteries is crucial as these wounds have a very high lethality.20 This iliac vascular control can be achieved with clamps, vessel loops or Rommel tourniquets based on facility resources. Achieving hemorrhage control must be prioritized, but the risk of ischemic tissue at the site of injury and subsequent infection, overwhelming infection, and diminished wound healing must be recognized.

Proximal control, particularly when involving ligation of iliac vessels, should not be done as it is associated with significant pelvic girdle, perineum, and thigh necrosis, as well as angioinvasive fungal infections, potentially leading to hip disarticulation or trans-pelvic amputation, hemicorpectomy and death.21 An attempt to re-perfuse the internal iliac arteries should be made at the index or subsequent procedure. Ligation of both internal iliac arteries must be avoided if at all possible. However, in cases of ongoing pelvic hemorrhage despite pelvic packing and angiographic embolization, bilateral internal iliac artery temporary occlusion may be necessary. These casualties must return to the OR, because significant tissue necrosis should be anticipated. In the case of prolonged warm ischemia time, prophylactic fasciotomies of the residual limb are often necessary as compartment syndrome occurs frequently, even in the presence of large open wounds.

Refer to JTS Acute Extremity Compartment Syndrome and the Role of Fasciotomy in Extremity War Wounds CPG for further guidance.22