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Cardiovascular and thoracic battle injuries in the Lebanon War
J
THoRAc CARDIOVASC SURG
89:723-733, 1985
Cardiovascular and thoracic battle injuries in the Lebanon War Analysis of 3,000 personal cases This report comprises 3,000 casualties of the Lebanon War whom I operated upon for cardiovascularthoracic injuries in twelve Lebanese hospitals between January, 1969, and July, 1982. These patients were studied retrospectively through 1978 and prospectively thereafter. The logistics, weapons, wounds, and operative results in this study were unique. The patients' injuries can be categorized as follows: primarily thoracic, 1,251 (42%); peripheral vascular, 1,008 (34%); cardiac, 285 (9%); and thoracic mixed, 456 (15%). The male to female ratio was 3.6:1, the mean age 20 years, and the military to civilian ratio 1.7:1. The mean transport distance was 2 miles in 1,740 patients (58%). In patients with thoracic wounds, the incidence of cardiac involvement (14 %) was higher than in World War II and Vietnam. The overall survival rate in casualties with cardiac injuries was 73 % -best in pericardia), coronary, and right atrial wounds and dropping to 46% in left ventricular wounds, wherein pump failure was also a factor. A 13% (seven deaths) mortality for patients with injuries to the thoracic great vessels contrasted with the 1.2 % (14 deaths) mortality for the rest of the patients with noncardiac thoracic wounds. Open thoracotomy in 818 operations (55%) reflected massive wounds and logistics. Pulmonary resection (310 operations) carried a 1.9% (five deaths) mortality and tube thoracostomy (683 operations) for lesser injuries, 0.7% (four deaths.) Thoracoabdominal injuries were 1.5 times more lethal Fifty percent (504) of nonthoracic vascular wounds occurred in the femoral-popliteal area as a result of sniper attacks. Subin~a1 damage averaged 8 cm and mandated saphenous vein grafts in 72 %. The mortality for injury to the aorta was 60% (12 deaths), contrasted with 1 % (three deaths) for injury to extremity vessels. Hemorrhage and cardiac rupture were the most frequent causes of death. Early, proficient, open surgical control after or concomitant with intensive resuscitation proved successful in this special military conflict.
Alex T. Zakharia, M.D., F.A.C.S., Miami, Fla.
his paper is an overall study of three thousand cardiovascular and thoracic battle injuries in Lebanon, treated between January, 1969, and July, 1982. The review is unique in that all operations and the specialty care were uniformly performed by the author. The study was retrospective until 1978 and prospective thereafter, from admissions to twelve hospitals during different stages of the war (Fig. 1). Historically, Lebanon was the established referral center for the Middle East, hosting international surgical societies, professional surgeons, Received for publication April 6. 1984. Accepted for publication May 16, 1984. Address for reprints: Alex T. Zakharia, M.D., F.A.C.S., Assistant Professor of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Miami School of Medicine, P.O. Box 016960, Miami, Fla. 33101.
and hospitals. Credit goes to outstanding American surgeons at the American University of Beirut and others, including Whipple, McDonald, Churchill, Simeone, Wilson, and DeBakey. Despite this professional setting, coping with increasing specialty casualties caused by varied mechanisms proved a unique and trying experience (Fig. 2). New, advanced weapons included a wide range of high-velocity missiles (Table I). In response, hospitals improved emergency, operating, and intensive care facilities. Civil Defense, Red Cross, and Red Crescent teams received regular training in rapid evacuation and field resuscitation. Ambulance oxygen and intravenous support became standardized. New emergency hospitals were developed. One logistic and qualitative advance was direct evacuation of many cardiovascular and thoracic casualties to a fully special723
724
The Journal of Thoracic and Cardiovascular Surgery
Zakharia
Table I. Sample weaponry in the Lebanon War High-velocity rifles
Katyusha
MI6 automatic
Grad
ISS mm
Kalashnikov Soviet AKM
Antitank B7 Air to land; sea to land
120 mm
Table
Fig. 1. Hospitals where operations on the 3,000 casualties were performed.
ized hospital established by the Arab Research Center for Injuries in 1977.' Nevertheless, during catastrophic times of city warfare, important deficiencies existed: failure of electrical power, cutoff of water supply, shortage of generator fuel, shortage of anesthetic agents, shortage of oxygen, shortage of operating room supplies, shortage of food, poor sanitation, shortage of medical personnel, termination of transport routes, and bombardment of hospitals.
Patients Between January, 1969, and July, 1982, I operated upon and attended 3,000 casualties with cardiovascular and thoracic wounds in 12 hospitals in Lebanon (Fig. 1). When Beirut became battle divided in 1976, all injuries were from West Side hospitals. Relevant data were reviewed during 1974, 1977, 1980, and 1983. Detailed documentation was absent at times of major battles or mass casualties. By 1973, standardized records were required for hospital reimbursement by the Ministry of Health and the Social Security Medical Division. Valuable medical studies were dispersed as many hospitals were damaged. Better follow-up data were available in the group of patients who required further operations, such as decortication, aneurysmectomy, cardiac, and
Dynamite
Rockets
MIS automatic
Trinitrotoluene (TNT) Advanced plastics Phosphorus
n. Distribution of 3,000 casualties Sites
No. of casualties
Thoracic Peripheral vascular Cardiac Thoracic, miscellaneous
1,251 1,008 285 456
41.7 33.6 9.5 15.2
Total
3,000
100.0
%
reconstructive operations. Few patients were transferred to medical centers outside Lebanon. Table II shows the distribution with regard to sites of injury. Thoracic noncardiac casualties comprised 57% and cardiovascular casualties 43%. The male to female ratio was 3.6 to 1. Sixty percent were between 10 and 30 years of age, the mean age for the entire group being 20 years (Fig. 3). Sixty-three percent were military personnel and 37% civilians. Reliable estimates of distances indicated that 58% of injuries occurred within 2 miles of the treating hospital (Fig. 4). Methods of transportation included ambulances, military vehicles, cars, and assistance from bystanders. Forty-one casualties (1.4%) were wounded inside or near a hospital. In 78% of individual casualties, the time lag from injury to emergency room was under 4 minutes, but this time period was longer in conditions of mass casualties and difficult access. Among the 400 patients evacuated in two groups by the International Red Cross from the besieged Tal AI Zaatar camp, 17 survived thoracic and cardiovascular wounds, having received limited medical care for weeks. Evaluation of physical facilities showed that 14% of operations were performed under stressful and rudimentary war conditions. Inadequate lighting was noted in 87 operations (3%), poor sterile setup in 71 (2.4%), and lack of proper equipment in 55 others (1.8%). Fortyseven percent of operations were performed during active city battles, but results were not significantly different from those in the rest of the patients. Review of anesthesiologist performance showed high proficiency,
Volume 89
Battle injuries in Lebanon War
Number 5
725
May. 1985
11l
1100
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100
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Beirut battles
car bombs
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South Lebanon Training camps Beirut clashes air raids
East
Snipers
Beirut
Battles on all fronts
troops
Car bombs
Air raids Lebanon invasions Naval shelling Fragmentation weapons
Civil riots Small arms
car bombs
1969-1970
1971-1974
1975-1976
1977
1978-1981
1982
(50 per yearl
175 per yearl
1475 per year)
1300 per year)
1275 per year)
(350 per year)
clashes
Fig. 2. Mechanisms of injuries by time periods,
emphasizing early postoperative awakening. Only 8% of the postoperative patients were admitted to intensive care units. Blood requirements varied from zero to 69 units, with an average of 4 units. Forty percent was drawn from volunteer donors and the rest from professionals. An average of 18 L of intravenous fluid solutions and 60 gm of antibiotics was utilized per patient admission. Approach to patients with critical injuries Critical cardiovascular and thoracic injuries increased by 1974, these increases reflecting the new arsenal deployed along proximal battle lines and hospital neighborhoods (Fig. 2). More casualties were retrieved alive as Beirut hospitals became transformed into full-time trauma centers. Rapid transportation was enhanced by vacant streets and short distances. It was common to receive a casualty 1 to 3 minutes after the injury. Around the clock hospital provisions included a senior surgeon, anesthetist, and residents covering the emergency and operating rooms. Voice communications, available in some centers, provided early notice to the cardiovascular surgeon and the emergency rooms. Effective emergency resuscitation for salvage followed the new local experience and that of others.>' An immediate intensive approach formulated total removal of clothes, securing the airway, installing multiple peripheral and central lines, and drawing a blood sample. Ringer's lactate, normal saline, or plasma solutions were rapidly infused, followed by blood. Simultaneously, a nasogastric tube, Foley catheter, and electrocardiographic monitor were placed, while overhead
900
en f-
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W600
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III
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Z300
AGE
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Fig. 3. Age distribution of the 3,000 casualties.
x-ray films were taken. Rapid body assessment located all entrance-exit wounds, associated injuries, and neurological status. Information from the ambulance attendant was included. Ninety-seven percent of thoracic and cardiac wounds were penetrating. An average of two chest tubes per patient were placed via the second and fifth intercostal spaces in the midaxillary line into either or both pleural cavities, depending on wound locations and x-ray fmdings. A pericardiocentesis was performed in certain cases," With resuscitation proceeding rapidly, the decision for defmitive treatment was guided by the following findings:
The Journal of
726
Zakharia
900
Thoracic and Cardiovascular Surgery
Table m. Evaluation of wounding agent to survival in cardiac wounds
en ~600 w
~
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::;: ~300
Fig. 4. Transportation distances of the 3,000 casualties.
1. The time lag since injury and the wounding history 2. The type of missile and wound sites 3. The depth of shock, its reponse to resuscitation, x-ray findings, and thoracostomy results 4. The presence of signs of life"? 5. The available logistics and options A short time lag allowed more persons with major thoracic and cardiac injuries to arrive alive. When decompensation occurred in the emergency room, despite active therapy, at least a cardiac tamponade was assumed. An urgent thoracotomy- 3. 5 in the emergency or preferably the operating room was rapidly performed. A left anterolateral thoracotomy with optional extension across the sternum was favored. Initial surgical correction included open relief of tamponade; control of cardiac perforation or major vessel bleeding by finger, suture, or clamp; and, when indicated, temporary clamping of the descending thoracic aorta.' Open cardiac resuscitation measures included manual massage, defibrillation, and bicarbonate, calcium, and inotropic drug infusions. Hemorrhage from the aorta, truncal vessels, or pulmonary hilum was controlled digitally and by clamping. For casualties who were dead on arrival with an unfavorable wounding history, resuscitation generally was not attempted.' In the group of patients undergoing thoracotomy in the emergency room,"" the best results were obtained in those in shock, in whom decompensation occurred after arrival in the hospital, and in whom the wounding history was favorable. A favorable wounding history consisted of a short retrieval time, a single wound caused by a low-velocitymissile fired from a long distance, and adequate life signs during transportation of the patient. The pivotal advantage of urgent thoracot-
Survived
--=
%
Shrapnel Gunshot Blast Blunt
159 120 3 3
56 42 I
72 I
1
2
84 60 33 66
Total
285
100
208
73
0: W
I
No.
Agent group
133
omy was hemorrhage control or cardiac resuscitation. Other benefits were the early diagnosis and repair of diaphragmatic, esophageal, and other wounds. In 27 casualties, the source of significant hemorrhage through the left tube thoracostomy was found at thoracotomy to be an injured spleen bleeding freely into the left pleural cavity via a ruptured diaphragm. Splenectomy was conveniently performed from the thoracic approach except in four patients, who required separate laparotomies for serious abdominal injuries. In 14 others, open thoracotomy showed the major right hemothorax to result from injuries of the diaphragm, liver, or hepatic or renal vessels. Repair was possible by extending to a thoracoabdominal incision in eight patients and by separate laparotomies in the remaining six. No anesthesia was required during urgent endotracheal intubation or the early part of open cardiac resuscitation. Survivors denied significant memory of these events. No preparation of the skin was performed in 55% of urgent thoracotomies. The skin was painted with preparatory solutions after successful operations, and no increase in wound infection was noted in this group. Total blood requirement in critically wounded patients varied from 4 to 70 units and averaged 12 units per patient, somewhat higher than in civilian injuries.' The hematocrit value of transfused blood units varied from 20% to 27%. The hematocrit value averaged 35% when drawn from family members and volunteers but only 24% when obtained from professional donors. Eighty percent of transfusion problems related to the latter source.
Results Cardiac IDJunes. The mean age was 18 years. High-velocity missiles such as the M15, M16, and Kalashnikov rifles caused small entrance wounds, wide internal cavitation effects, and major transverse "burning" damages. Gunshot wounds caused 42% of cardiac injuries, shrapnel 56%, and blast and blunt injuries 1% each (Table III). Cardiac wounds comprised 285 of the 1,992 thoracic
Volume 89
Battle injuries in Lebanon War
Number 5
'7 2 7
May, 1985
Table IV. Clinical state and survival in cardiac
.
injuries 120
Clinical state or structure
Profound shock Mild shock or tamponade Mainly pericardiaI injury
%
87 188
53 146
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9
90
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~ 30
Table V. Distribution of 456 thoracic mixed injuries No. of casualties
Associated system
Thoraco-pcripheral vascular Thoraco-spinalcord Thoracocranial
55 21 9
Total
456
100
Thoraco-orthopedic
20
8
7
Table VI. Mortality in primarily thoracic casualties
Tube thoracostomy Resection Pulmonary hemorrhage Decortication Air leak Chest wall Esophagus Mammary jintercostals Great vessels Total
%
570 258 140 68 61 52 8 40 54 1,251
4 5 2 2 0 0 0 7
0.7 1.9 1.4 1.5 3.3 0 0 0 13.0
21
1.7
I
injuries, a 14% incidence, which is higher than the 3.3% incidence reported from World War 1I13 and the 2.8% incidence recorded in a report from Vietnam." The difference is probably related to special logistics in the Lebanon War. Prehospital mortality among cardiac injuries in World War II was reported at 84%15 and in major United States civilian reports, from 62% to 83%.2,9,16,17 We were unable to accurately assess the prehospital deaths since very few autopsies were performed. Cardiac survival statistics were influenced by early arrival of casualties, major weaponry, preparation of hospitals, and urgent surgical treatment. The overall survival rate in our 285 patients with cardiac wounds was 73% and includes all persons with
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~
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Procedure/organ
\
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THORACOTOMY 818 operations 54.5% Pulmonary resection 310 20.7% Control pulmonary hemorrhage 17011.3% Non pulmonary hemorrhage 112 7.5% 81 5.4% Decortication Major air leaks 73 4.9% Chest wall repair 62 4.1 % 10 0.7% Esophagus
Procedure and Frequency
Fig. 6. Analysis of 1,501 procedures for 1,251 casualties with primarily thoracic injuries.
cardiac injuries who arrived in emergency rooms with signs of life. A 60% survival rate was reported from World War 11,13 and Mattox and associates' reported a 67.5% survival rate in a group of civilians with severe gunshot wounds of the heart. Table IV shows survival relationships to clinical state. Cardiac wounds were multiple in 37 patients, with a survival rate of 51%. Fig. 5 shows the location of cardiac wounds with preponderance to the right ventricle and atrium, and the relationships to survival. Despite urgent surgical intervention in our series, the survival rate in persons with left ventricular wounds was 46%, and a clinical picture of pump failure was noted in 50%.
7 2 8 Zakharia
The causes of death in 80% of patients with cardiac injuries seemed directly related to the extent and complications of the cardiac wounds. Cardiac hemorrhage accounted for 30%, ventricular arrhythmias 12%, cerebral anoxia 18%, and noncardiac wounds 15%. Associated organ injuries were present in 88% of casualties. The organs most commonly injured were the lungs (68%), diaphragm (59%), liver (38%), and stomach (21%). Long-term folow-up confirmed the presence of relatively few sequelae, notably cardiac arrhythmias, psychological changes," interventricular dyskinesias, and postpericardiectomy syndrome. The removal of fragments and bullets was routinely attempted to reduce the need for secondary operations." Thoracic injuries. Tables II and V show the breakdown of thoracic casualties. Among 1,707 persons with thoracic noncardiac injuries, the central medical problem was the thoracic injury in 1,251 (73%). In the remaining 456 patients (27%), at least one nonthoracic organ was seriously injured. Ninety-seven percent of wounds were penetrating, caused by shrapnel (57%) and bullets (43%). Fig. 6 outlines the operations in the group with primary thoracic injuries. An average of 1.2 operations per patient was noted. In 45%, tube thoracostomy, with an average of two tubes per patient, was the definitive operative therapy. Appropriate techniques for this vital procedure have been emphasized elsewhere.19, 20 Prior to tube insertion, a gloved finger was passed through the thoracostomy incision to identify adhesions, lung collapse, diaphragmatic rupture, and visceral herniation into the chest. Three nonfatal technical complications from tube thoracostomy were noted. The average operative time in 818 thoracotomies was 104 minutes and the mean blood replacement, 1,350 mi. No demonstrable increase in mortality or morbidity was due to the technical procedure. An anterolateral approach was used in 50%, posterolateral in 44%, and midsternotomy in 6%. The choice of incision was guided by wound sites and clinical findings. Among 310 pulmonary resections, there were 162 segmental resections, 112 lobectomies, and 36 pneumonectomies. A frequent finding was a tom, semidetached pulmonary segment caused by a large-caliber missile or fragment, requiring completion resection and debridement. The mortality results are outlined in Table VI, the highest number of deaths (13%) resulting from great vessel injuries. These 54 patients, accounting for 4.3% of the primary thoracic group, influenced overall results. The mortality for all 1,251 thoracic patients excluding those with great vessel injuries was 1.2% and including those with vessel injuries, 1.7%. The mortality for open
The Journal of Thoracic and Cardiovascular Surgery
thoracotomy excluding great vessel injuries was 1.7% and including vessel injuries, 3.1%. The lowest mortality (0.7%) was in the 570 patients treated by tube thoracostomy. Of 73 thoracotomies for air leaks, plastic repair of the trachea or a major bronchus was done in 42% and suturing of smaller bronchial tears in 58%. Four of the eight esophageal penetrating injuries were diagnosed at early thoracotomy and the rest by nasogastric intubation and esophagography." The extent of esophageal injury was beyond simple suture repair in six." Because all were operated upon within hours of injury, there was no need for esophageal diversions or exclusions." Six perforations were in the lower third of the esophagus, and gastric patch onlays were successful in all." Pleural wraps were successful for the other two perforations in the middle esophagus. There were three anastomotic leaks with localized mediastinitis controlled by hydration and antibiotic therapy. Two persons with thoracic aortic injuries survived simultaneous resuscitation and operation as described elsewhere." Temporary cross-clamping of the descending aorta and application of a side-biting clamp to the perforated aorta preceded the repairs. Innominate vessel wounds were approached via the midsternotomy plus anterior thoracotomy book incision." Bypass grafts were employed in 78% and angioplastic repair in 28%. Injured thoracic veins were repaired when feasible. The mixed injuries are shown in Table V. Minor thoracic wounds were excluded. Mortality was 1.5 times greater in the group with thoracoabdominal wounds than in those with primary thoracic injuries, and the incidence of systemic complications and deep vein phlebitis was 2.7 times higher. Surgical priority was given to suspected cardiac and great vessel wounds, with special attention to the abdomen in lower thoracic wounds. The abdominal organs most frequently wounded were the liver (36%), stomach (31%), spleen (27%), and small intestines (24%). Diaphragmatic repair was routinely performed regardless of perforation size. There was no documentation of a repair disruption. Highvelocity missiles crossing the posterior mediastinum produced spinal cord injuries in seven patients despite absence of vertebral fractures. A burnlike effect with liquefaction of the spinal cord was found at laminectomy. There were 81 thoracic injuries in children under 12 years, an incidence of 4.7%. Penetrating wounds comprised 85%, blunt 13%, traumatic asphyxia 3%, and bum inhalation injuries 2%. Traumatic asphyxia resulted from chest wall compression by collapsed building walls; salvage by tube thoracostomy for hemopneumothorax along with intensive care measures was successful in all four children." Smoke from burning
Volume 89 Number 5 May, 1985
Table
Battle injuries in Lebanon War
729
vn. Mortality in 1,008 persons with nonthoracic vascular wounds Deaths Vessels
Femoral artery Femoral vein Femoral artery and vein Popliteal artery Popliteal vein Popliteal artery and vein Subclavian artery Subclavian vein Subclavian artery and vein Axillary artery Axillary vein Axillary artery and vein Brachial artery Abdominal aorta Inferior vena cava Abdominal aorta and inferior vena cava Renal artery Iliac artery Iliac vein Iliac artery and vein Common carotid artery Internal carotid artery External carotid artery Internal jugular vein Tibial artery Total
No. of patients
192 54 125 23 7 103 38 6 5 10 5 7 127 19 14 3 6 69 IS 21 15 52 22 10 60 1,008
homes caused serious inhalation bums in two children. Active pulmonary toilet, bronchoscopy, and bronchodilators were effective.28 Mortality in civilian reports for pediatric thoracic injuries varies from 7% to 14%.29.33 In this series five children died, an incidence of 6.2%. Two of the deaths were due to associated intra-abdominal wounds. Chylothorax in two children resulted from penetrating injuries to the left side of the chest. Supradiaphragmatic ligation with silk suture was successful in both. Mixed thoracoabdominal penetrating wounds were present in 45% of children. Complications in the 1,707 persons with thoracic injuries included atelectasis, minor chest tube complications, and surgical wound infection (0.5%). For pulmonary resections and tracheobronchoplasties, the incidence of bronchopleural fistula was 4%. Postoperative empyema was rare in patients operated upon promptly. However, in 17 casualties evacuated to the hospital weeks after thoracic injury, the incidence of empyema was 70%; four patients (24%) eventually required pleuropneumonectomies, the rest requiring multiple surgical procedures and prolonged hospitalizations. Air embolism was the apparent cause of death in two patients. Awareness of this condition was helpful in one
No. I
0 I 0 0 0 0 0 I 0 0
a a
I
%
0.5 0 1.0 0 0 0 0 0 20 0
a a a
12 7 2
63 50 67
13 2 6 2 3
19 13 29 13 3.8
a
a I
a 51
Vein association (%)
34 77
12 32
a
20
a
10
a
5.1
casualty in whom mild shock and cerebral signs were present. A head-down position, occlusion of the distal thoracic aorta, and cardiac massage to drive the air out of the coronary circulation probably contributed to his salvage." Special complications were noted in 60% of patients with thoracospinal injuries. These were bronchopneumonia, sepsis, recurrent urinary tract infection, bed sores, and wound dehiscence. Active psychiatric and social support was highly demanded in this subgroup of unfortunate patients. Vascular (nonthoracic) injuries. Excellent reviews of vascular injuries for World War II and the Korean and Vietnam conflicts were recorded by Elkin and DeBakey," DeBakey and Simeone," Hughes," and Rich, Baugh, and Hughes." Important and unique findings also observed in our study are summarized. Despite massive cavitary wounds formed by highvelocity missiles, the mortality and morbidity in extremity vascular wounds was low (Table VII). Unexpectedly, 50% of nonthoracic vascular injuries occurred in the femoral and popliteal areas, prime targets for rooftop professional snipers (Fig. 7). Concomitant deep vein injury was recorded in two thirds of patients with popliteal and one third of those with femoral and
730
The Journal of Thoracic and Cardiovascular Surgery
Zakharia
570
540510
504
480 450 (J)
UJ
~ ...J
:3
420 390 360
(J)
u
u,
o
300
a:: 270 UJ
~ 240
~ 210 180
150 120
99
90
60 30 Femoral Popliteal
Subclavian Brachial
Abdominal Aorta Iliac
Carotid
Tibial
Fig. 7. Analysis of nonthoracic vascular wounds sites (1,008 total wounds). axillary wounds. The popliteal nerve was injured in 40% of popliteal vessel wounds and bony fractures occurred in 22% of extremity injuries. Penetrating high-velocity missiles and fragments accounted for 97% of vessel wounds. Truncal injuries presented with hypovolemic shock, and extremity injuries presented with active bleeding or hematoma. Pulse deficits distal to the injured artery were noted in 85% and skeletal muscle ischemia was observed within 7 hours of injury. Arteriography, rarely used acutely (3%), was useful in false, arteriovenous aneurysms and long-standing vessel injuries. In 12 abdominal aortic wounds, death was directly caused by exsanguination and shock. Persons with suspected aortic injuries were operated upon urgently, with rapid exposure and manual compression applied, as proximal and distal control was attained. Aortic prosthetic grafts were used in two of seven salvaged patients. In four of eight patients dying of vena caval injuries, the injury involved the hepatic portion. Angioplastic repair or ligation was successful in seven persons with caval injuries. Carotid wounds were repaired by patch graft angioplasty (45%), prosthetic grafts (38%), and suture repairs (17%). An internal shunt was employed in 30%. Uneventful resection of 12 false carotid aneurysms was noted, with reversal of hemiparesis in six of eight patients operated upon for carotid-jugular communications. The extrathoracic subclavian vessels were uniformly
exposed by resection of the medial two thirds of the clavicle. Prosthetic grafts were employed in 70% of arterial wounds. Patch angioplasty or suture repair was used in 17 of 26 (65%) venous repairs. Ligation was employed in the remaining nine subclavian vein injuries, with arm edema persisting in two. One forearm amputation followed the resection of a massive false aneurysm of the axillary artery in a boy with hand ischemia referred 32 days after trauma. Vein grafts were preferred in axillary and brachial arterial repairs. An average of 1.7 vascular operations per patient was noted in 504 femoral and popliteal injuries. The saphenous vein was the preferred conduit, used in 72%. Direct suture of the ruptured artery was abandoned very early, and deep vein reconstruction was routinely attempted. When deep vein ligation was mandatory, a long fasciotomy was performed. Distal vessel irrigation with heparinized saline and final Fogarty catheter evacuations were undertaken routinely. Fracture stabilization was done by internal fixation (31%), skeletal traction (54%), and bivalved casts (15%). One patient developed gas gangrene 18 hours after reconstruction of the femoral artery and died despite amputation and active treatment. The metabolic syndrome" in various forms of severity was noted in 16 patients and may have accounted for three deaths. There were 49 patients with massive femoral or popliteal injuries who required at least six vascular procedures, with 95% limb salvage. The incidence of amputations was highest in popliteal wounds (6%),
Volume 89 Number 5
Battle injuries in Lebanon War
73 1
May. 1985
followed by femoral wounds (1.3%). Popliteal nerve reconstruction was performed at the same time as vascular repair, by logistic necessity, in 70% and after 6 weeks in 30%. No significant differences in results for the two groups was noted, and chronic nerve problems persisted in 40%.
Discussion The incessant barrage of modem high-velocity missiles and rockets fired at close ranges resulted in extensive cardiovascular and thoracic injuries. Rapid patient retrieval mandated effective resuscitation and urgent surgical control. The availability of blood, the young age group, and the active compassion for the wounded were favorable. The highest personal daily count was 11 major specialty operations. As technical proficiency in surgical exposures and corrections developed, operative time was reduced and salvage significantly improved. Only minor differences in results were documented when operations were performed during active battle conditions with stringent operating facilities. Among 3,000 casualties in this study, the highest mortality rates were among those with cardiac, aortoiliac,and thoracic great vessel injuries: Hemorrhage was the most frequent underlying cause of death and cardiac rupture the second. The specialized cardiovascular and thoracic center provided the following advantages: 1. A central unit for early treatment of specialty injuries 2. Updated equipment including cardiopulmonary bypass andautotransfusion pumps 3. Underground adjacent emergency operating and radiology suites within direct reach of ambulances In cardiac wounds, predetermined factors influenced ultimate survival. One was the proximity, multiplicity, and type of firing agents. Another was dampening of missiles during their initial passage through walls, special clothing, sternum, ribs, scapula, or the arm. The site of cardiac injury was relevant, left ventricular wounds being the most deadly,' followed by multiple cardiac wounds, and those of the posterior wall. In the last group, one limiting factor during operations was the frequency of ventricular fibrillation upon lifting of the heart for exposure.' Fifty percent of patients dying of left ventricular wounds had pump failure resistant to pharmacologic support. We believe that mechanical cardiac support could prove valuable in such selected patients. Most cardiac lacerations were repaired with pledget-
reinforced mattress sutures. Bleeding coronary vessels were suture ligated in seven patients and suture repaired in two others." No clinical sequelae were noted on follow-up of all nine patients, although stable electrocardiographic changes were present in five. In thoracic injuries, the principles of treatment of open pneumothorax, paradoxical chest motion, tension pneumothorax, and sucking wounds all have been well described elsewhere.":" Fifty-five percent of patients with primarily thoracic injuries underwent open thoracotomy, a greater incidence than in civilian reports."" Tube thoracostomies were the definitive operation in patients with milder injuries, and the mortality was 0.7%. When cardiac and great vessel injuries are excluded, the mortality among thoracotomy patients (681) was only 1.7%. Thoracotomy, also effective in reducing ventilatory deaths in bronchopulmonary injuries, if proficiently performed, has comparable safety in a military setting. The indications for thoracotomy were well documented elsewhere. 19,34.42.43,45,46 In the Lebanon battles, special factors made early thoracotomy a choice option. Serious personnel, diagnostic, and equipment shortages reduced the validity of Conservative approaches." A modem variety of military weapons causing extensive wounds, with significant blood loss and shock in young patients, mandated secure open surgical control. Open thoracotomy allows effective control of hemorrhage, major air leaks, treatment of pulmonary rupture, decortication, and debridement. Diaphragmatic'>" and esophageal": 22, 50 injuries are confirmed and treated before complications of delay set in. The same applies for relief of cardiac tamponade" and the removal of bullets and fragments when proximal to vessels, esophagus, or trachea." Mixed thoracic injuries carried a 50% higher mortality. Increased complications were notable among associated spinal cord injuries. In thoracic abdominal injuries, life-threatening hemorrhage in both cavities necessitated simultaneous surgical control, with abdominal priority in some." In children special critieria were strictly applied. These included rapid correction of hypovolemia before shock occurred, early thoracostomy to correct or prevent shifts of the freely mobile mediastinum, nasogastric intubation for aerophagia, and urgent thoracotomy whenever indicated. The low mortality also reflected persistence in treatment. The relative inadequacy of arterial suture repairs and end-to-end arterial reconstruction for high-velocity missile wounds was evidenced by a 42% incidence of
732
The Journal of Thoracic and Cardiovascular
Zakharia
disruption with such methods early in our experience. Suture line disruptions, heralded by sudden hemorrhage or pulsatile hematoma bulging under the skin closure, occurred most frequently on the sixth postoperative day (56%). The arterial wall was notably edematous with partial necrosis of the suture line. Cultures or smears were positive in 30%. We found subintimal arterial wall damage to extend beyond the apparent rupture proximally and distally for an average total distance of 8 cm. To ensure success of the secondary bypass procedure, we constructed the proximal and distal anastomoses at least 10 em from either direction of the necrosed suture line. A less radical approach was rarely successful. Persistence in limb revascularization in young patients is essential and rewarding. One such patient underwent eight femoral-popliteal vascular operations within 2 months with excellent results. Wound management included radical debridement and cavitary hemostasis. The subcutaneous tissue was left open in 40%, and secondary closure was performed around the third postoperative day. The contralateral saphenous vein was the preferred bypass conduit for combined arterial and deep vein wounds. Deep vein repairs were routinely attempted, but when ligated by necessity, a simultaneous distal fasciotomy was performed. Embolectomy was the most common secondary operation, performed in 18%. Lumbar sympathectomy for causalgia produced favorable results in selected patients with popliteal arterial problems. Chronic neurological signs and symptoms were common in popliteal triad injuries, whether primary or secondary nerve repair was performed. After angiographic delineation, arteriovenous aneurysms or communications were approached by ligating and dividing the layers of distended superficial veins. Proximal and distal control of the involved vessels usually was easy and the fistula was divided. Arterial repair was performed by angioplasty or by interposition of a prosthesis or vein graft. False aneurysms can reach huge sizes, at times precluding adequate proximal and distal control. I found it safe and expedient to approach extrathoracic aneurysms directly. With proper timing, the false hematoma can be rapidly removed and the arterial tear directly exposed and digitally controlled. Removal of the hematoma now allows excellent proximal and distal arterial control and reconstruction of the vessel. This approach is not appropriate for intrathoracic vascular aneurysms. I am grateful to Drs. M. E. DeBakey, F. A. Simeone, R. Hopkins, and J. Jude for their helpful personal communications since 1978 which guided this project.
Surgery
REFERENCES Zakharia AT: Cardiovascular and thoracic trauma center. Archives of the Arab Research Center for Injuries, 1977, Beirut, Lebanon 2 Sugg WL, Rea WJ, Ecker RR, Webb WR, Rose EF, Shaw RR: Penetrating wounds of the heart. An analysis of 459 cases. J THORAC CARDIOVASC SURG 56:531-545, 1968 3 Mattox KL, Beall AC Jr, Jordan GL, DeBakey ME: Cardiorrhaphy in the emergency center. J THORAC CARDIOVASC SURG 68:886-895, 1974 4 Bodai BI, Smith JP, Ward RE, O'Neill MB, Auburg R: Emergency thoracotomy in the management of trauma. JAMA 249:1891-1896,1983 5 Rohman M, Ivatury RR, Steichen FM, Gaudino J, Nallathambi MN, Khan M, Stahl WM: Emergency room thoracotomy for penetrating cardiac injuries. J Trauma 23:570-576, 1983 6 Baker CC, Thomas AN, Trunkey DD: The role of emergency room thoracotomy in trauma. J Trauma 20:848-855, 1980 7 Flynn TC, Ware RE, Miller PW: Emergency room thoracotomy. Ann Emerg Med 11:413-416, 1982 8 Knott-Craig CJ, Przybojewski JZ, Barnard PM: Penetrating wounds of the heart and great vessels. A new therapeutic approach. S Afr Med J 62:316-320, 1982 9 Beall AL, Ochsner JL, Morris GC Jr, Cooley DA, DeBakey ME: Penetrating wounds of the heart. J Trauma 1:195-207, 1961 10 Steichen FM, Dargan EL, Efron G, Pearlman DM, Weil PH: A graded approach to the management of penetrating wounds to the heart. Arch Surg 103:574-580, 1971 11 Hardy JD, Williams RD: Penetrating heart wounds. Analysis of 12 consecutive cases individualized without mortality. Ann Surg 166:228-231, 1967 12 Carrasqvilla C, Wilson RE, Wait AJ, Arbulu A: Gunshot wounds of the heart. Ann Thorac Surg 13:208-213, 1972 13 Berry FF, ed.: Surgery in World War II, Thoracic Surgery, Office of the Surgeon General, Department of the Army, Vol 1, 1963, Vol. II, 1965 14 Gielchinsky I, McNamara JJ: Cardiac wounds at a military evacuation hospital in Vietnam. J THORAC CARDIOVASC SURG 60:603-606, 1970 15 Parmly LF, Mattingly TW, Manion WM: Penetrating wounds of the heart and aorta. Circulation 17:953-973, 1958 16 Maynard AL, Brooks HA, Froix GJ: Penetrating wounds of the heart. Arch Surg 90:680-686, 1965 17 Boyd JS, Streider JW: Immediate surgery for traumatic heart disease. J THORAC CARDIOVASC SURG 50:305-315, 1965 18 Abbot JA, Cousineau M, Chetlin M, Thomas AN, Lim RC Jr: Late sequelae of penetrating cardiac wounds. J THORAC CARDIOVASC SURG 75:510-518, 1975 19 Bonnabeau RC: Penetrating thoracic trauma. Minn Med 57:270-278, 1974
Volume 89 Number 5 May, 1985
20 Millikan JS, Moore EE, Steiner E: Complications of tube thoracostomy for acute trauma. Am J Surg 140:738-741, 1980 21 Schein M, Pool R, Conlan AA: Late management of penetrating oesophageal injury. S Afr Med J 63:456-458, 1983 22 Symbas PN, Hatcher CR, Vlasis SE: Esophageal gunshot wounds injuries. Ann Surg 191:703-707, 1980 23 Urschel HC, Razzuk MA, Wood RE, Galbraith N, Pockey M, Paulson DL: Improved management of esophageal perforation. Exclusion and diversion in continuity. Ann Surg 179:587-591, 1974 24 Robinson JC, Isa SS, Spees EK: Substernal gastric bypass for palliation of esopheageal carcinoma. Rationale and technique. Surgery 91:305-311,1982 25 Reul GJ, Beall AC Jr, Jordan GL, Mattox KL: The early operative management of injuries to the great vessels. Surgery 74:862-873, 1973 26 Graham JM, Feliciano DV, Mattox KL, Beall AC, DeBakey ME: Management of subclavian vascular injuries. J Trauma 20:537-544, 1980 27 Jones J: The management of traumatic asphyxia. Case report and literature review. J Trauma 16:235-238, 1976 28 Moylan JA: Smoke inhalation and burn injury. Surg Clin North Am 60: 1533-1540, 1980 29 Erchelberger MR, Randolph JG: Thoracic trauma in children. Surg Clin North Am 61:1181-1197, 1981 30 Mayer T, Matlak M, Johnson J, Walker ML: The modified injury severity scale in pediatric multiple trauma patients. J Pediatr Surg 15:719-726, 1980 31 Sinclair MC, Moore T: Major surgery for abdominal and thoracic trauma in childhood and adolescence. J Pediatr Surg 9:155-162,1974 32 Smyth BT: Chest trauma in children. J Pediatr Surg 14:41-47, 1979 33 Welch KJ: Thoracic injuries, The Injured Child, JG Randolph et ai, eds., Chicago, 1980, Year Book Medical Publishers, Inc., pp 213-215 34 Thomas AN: Penetrating thoracic trauma (Trauma Rounds). West J Med 121:510-514, 1974 35 Elkin DC, DeBakey ME: Surgery in Wolrd War II, Vascular Surgery, Washington, D. C; 1955, Office of the Surgeon General, Department of the Army
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36 DeBakey ME, Simeone FA: Battle injuries of arteries in World War II. An analysis of 2,471 cases. Ann Surg 123:534-579, 1946 37 Hughes CW: Acute vascular trauma in Korean War casualties. An analysis of 180 cases. Surg Gynecol Obstet 99:91-100, 1954 38 Rich NM, Baugh JH, Hughes CW: Acute arterial injuries in Vietnam: 1,000 cases. J Trauma 10:359-368, 1970 39 Haimovici H: Metabolic syndrome secondary to acute arterial occlusions, Vascular Emergencies, H Haimovici, ed., New York, 1982, Appleton-Century-Crofts, pp 267289 40 Espada R, Whisennand HH, Mattox KL, Beall AC Jr: Surgical management of penetrating injuries of the coronary arteries. Surgery 78: 755-760, 1975 41 Lewis FR: Thoracic trauma. Surg Clin North Am 62:97103, 1982 42 Webb WR: Thoracic trauma. Surg Clin North Am 54:1179-1192, 1974 43 Richardson JD: Management of noncardiac thoracic trauma. Heart Lung 7:286-292, 1978 44 Hughes R: Thoracic trauma. Surg Clin North Am 48:759- 771, 1968 45 Tayos MS, Guzman DD: Management of 115 cases of thoracic trauma. Emphasis on 44 penetrating injuries. JAMA 43:267-283, 1967 46 Blalock JB, Ochsner JL: Management of thoracic trauma. Surg Clin North Am 46:1513-1524, 1966 47 Estrera AS, Platt MR, Mills LJ: Traumatic injuries of the diaphragm. Chest 75:306-313, 1979 48 Wise L, Connors J, Hwang YH: Traumatic injuries to the diaphragm. J Trauma 13:946-950, 1973 49 Sterns LP, Jensen NK, Schmidt WR: Diaphragmatic disruption in major thoracic trauma. A review of 16 cases. Can J Surg 12:426-431, 1969 50 Michel L, Grillo HC, Malt RA: Operative and nonoperative management of esophageal perforations. Ann Surg 194:57-63, 1981 51 Turney SZ, Attar S, Ayella R, Cowley RA, McLaughlin J: Traumatic rupture of the aorta. A five-year experience. J THoRAc CARDIOVASC SURG 72:727-734, 1976
THoRAc CARDIOVASC SURG
89:723-733, 1985
Cardiovascular and thoracic battle injuries in the Lebanon War Analysis of 3,000 personal cases This report comprises 3,000 casualties of the Lebanon War whom I operated upon for cardiovascularthoracic injuries in twelve Lebanese hospitals between January, 1969, and July, 1982. These patients were studied retrospectively through 1978 and prospectively thereafter. The logistics, weapons, wounds, and operative results in this study were unique. The patients' injuries can be categorized as follows: primarily thoracic, 1,251 (42%); peripheral vascular, 1,008 (34%); cardiac, 285 (9%); and thoracic mixed, 456 (15%). The male to female ratio was 3.6:1, the mean age 20 years, and the military to civilian ratio 1.7:1. The mean transport distance was 2 miles in 1,740 patients (58%). In patients with thoracic wounds, the incidence of cardiac involvement (14 %) was higher than in World War II and Vietnam. The overall survival rate in casualties with cardiac injuries was 73 % -best in pericardia), coronary, and right atrial wounds and dropping to 46% in left ventricular wounds, wherein pump failure was also a factor. A 13% (seven deaths) mortality for patients with injuries to the thoracic great vessels contrasted with the 1.2 % (14 deaths) mortality for the rest of the patients with noncardiac thoracic wounds. Open thoracotomy in 818 operations (55%) reflected massive wounds and logistics. Pulmonary resection (310 operations) carried a 1.9% (five deaths) mortality and tube thoracostomy (683 operations) for lesser injuries, 0.7% (four deaths.) Thoracoabdominal injuries were 1.5 times more lethal Fifty percent (504) of nonthoracic vascular wounds occurred in the femoral-popliteal area as a result of sniper attacks. Subin~a1 damage averaged 8 cm and mandated saphenous vein grafts in 72 %. The mortality for injury to the aorta was 60% (12 deaths), contrasted with 1 % (three deaths) for injury to extremity vessels. Hemorrhage and cardiac rupture were the most frequent causes of death. Early, proficient, open surgical control after or concomitant with intensive resuscitation proved successful in this special military conflict.
Alex T. Zakharia, M.D., F.A.C.S., Miami, Fla.
his paper is an overall study of three thousand cardiovascular and thoracic battle injuries in Lebanon, treated between January, 1969, and July, 1982. The review is unique in that all operations and the specialty care were uniformly performed by the author. The study was retrospective until 1978 and prospective thereafter, from admissions to twelve hospitals during different stages of the war (Fig. 1). Historically, Lebanon was the established referral center for the Middle East, hosting international surgical societies, professional surgeons, Received for publication April 6. 1984. Accepted for publication May 16, 1984. Address for reprints: Alex T. Zakharia, M.D., F.A.C.S., Assistant Professor of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Miami School of Medicine, P.O. Box 016960, Miami, Fla. 33101.
and hospitals. Credit goes to outstanding American surgeons at the American University of Beirut and others, including Whipple, McDonald, Churchill, Simeone, Wilson, and DeBakey. Despite this professional setting, coping with increasing specialty casualties caused by varied mechanisms proved a unique and trying experience (Fig. 2). New, advanced weapons included a wide range of high-velocity missiles (Table I). In response, hospitals improved emergency, operating, and intensive care facilities. Civil Defense, Red Cross, and Red Crescent teams received regular training in rapid evacuation and field resuscitation. Ambulance oxygen and intravenous support became standardized. New emergency hospitals were developed. One logistic and qualitative advance was direct evacuation of many cardiovascular and thoracic casualties to a fully special723
724
The Journal of Thoracic and Cardiovascular Surgery
Zakharia
Table I. Sample weaponry in the Lebanon War High-velocity rifles
Katyusha
MI6 automatic
Grad
ISS mm
Kalashnikov Soviet AKM
Antitank B7 Air to land; sea to land
120 mm
Table
Fig. 1. Hospitals where operations on the 3,000 casualties were performed.
ized hospital established by the Arab Research Center for Injuries in 1977.' Nevertheless, during catastrophic times of city warfare, important deficiencies existed: failure of electrical power, cutoff of water supply, shortage of generator fuel, shortage of anesthetic agents, shortage of oxygen, shortage of operating room supplies, shortage of food, poor sanitation, shortage of medical personnel, termination of transport routes, and bombardment of hospitals.
Patients Between January, 1969, and July, 1982, I operated upon and attended 3,000 casualties with cardiovascular and thoracic wounds in 12 hospitals in Lebanon (Fig. 1). When Beirut became battle divided in 1976, all injuries were from West Side hospitals. Relevant data were reviewed during 1974, 1977, 1980, and 1983. Detailed documentation was absent at times of major battles or mass casualties. By 1973, standardized records were required for hospital reimbursement by the Ministry of Health and the Social Security Medical Division. Valuable medical studies were dispersed as many hospitals were damaged. Better follow-up data were available in the group of patients who required further operations, such as decortication, aneurysmectomy, cardiac, and
Dynamite
Rockets
MIS automatic
Trinitrotoluene (TNT) Advanced plastics Phosphorus
n. Distribution of 3,000 casualties Sites
No. of casualties
Thoracic Peripheral vascular Cardiac Thoracic, miscellaneous
1,251 1,008 285 456
41.7 33.6 9.5 15.2
Total
3,000
100.0
%
reconstructive operations. Few patients were transferred to medical centers outside Lebanon. Table II shows the distribution with regard to sites of injury. Thoracic noncardiac casualties comprised 57% and cardiovascular casualties 43%. The male to female ratio was 3.6 to 1. Sixty percent were between 10 and 30 years of age, the mean age for the entire group being 20 years (Fig. 3). Sixty-three percent were military personnel and 37% civilians. Reliable estimates of distances indicated that 58% of injuries occurred within 2 miles of the treating hospital (Fig. 4). Methods of transportation included ambulances, military vehicles, cars, and assistance from bystanders. Forty-one casualties (1.4%) were wounded inside or near a hospital. In 78% of individual casualties, the time lag from injury to emergency room was under 4 minutes, but this time period was longer in conditions of mass casualties and difficult access. Among the 400 patients evacuated in two groups by the International Red Cross from the besieged Tal AI Zaatar camp, 17 survived thoracic and cardiovascular wounds, having received limited medical care for weeks. Evaluation of physical facilities showed that 14% of operations were performed under stressful and rudimentary war conditions. Inadequate lighting was noted in 87 operations (3%), poor sterile setup in 71 (2.4%), and lack of proper equipment in 55 others (1.8%). Fortyseven percent of operations were performed during active city battles, but results were not significantly different from those in the rest of the patients. Review of anesthesiologist performance showed high proficiency,
Volume 89
Battle injuries in Lebanon War
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May. 1985
11l
1100
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2
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700
100
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Beirut battles
car bombs
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-
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South Lebanon Training camps Beirut clashes air raids
East
Snipers
Beirut
Battles on all fronts
troops
Car bombs
Air raids Lebanon invasions Naval shelling Fragmentation weapons
Civil riots Small arms
car bombs
1969-1970
1971-1974
1975-1976
1977
1978-1981
1982
(50 per yearl
175 per yearl
1475 per year)
1300 per year)
1275 per year)
(350 per year)
clashes
Fig. 2. Mechanisms of injuries by time periods,
emphasizing early postoperative awakening. Only 8% of the postoperative patients were admitted to intensive care units. Blood requirements varied from zero to 69 units, with an average of 4 units. Forty percent was drawn from volunteer donors and the rest from professionals. An average of 18 L of intravenous fluid solutions and 60 gm of antibiotics was utilized per patient admission. Approach to patients with critical injuries Critical cardiovascular and thoracic injuries increased by 1974, these increases reflecting the new arsenal deployed along proximal battle lines and hospital neighborhoods (Fig. 2). More casualties were retrieved alive as Beirut hospitals became transformed into full-time trauma centers. Rapid transportation was enhanced by vacant streets and short distances. It was common to receive a casualty 1 to 3 minutes after the injury. Around the clock hospital provisions included a senior surgeon, anesthetist, and residents covering the emergency and operating rooms. Voice communications, available in some centers, provided early notice to the cardiovascular surgeon and the emergency rooms. Effective emergency resuscitation for salvage followed the new local experience and that of others.>' An immediate intensive approach formulated total removal of clothes, securing the airway, installing multiple peripheral and central lines, and drawing a blood sample. Ringer's lactate, normal saline, or plasma solutions were rapidly infused, followed by blood. Simultaneously, a nasogastric tube, Foley catheter, and electrocardiographic monitor were placed, while overhead
900
en f-
z
W600
~
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o
a: w
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::< =>
Z300
AGE
1.,.,.1
Fig. 3. Age distribution of the 3,000 casualties.
x-ray films were taken. Rapid body assessment located all entrance-exit wounds, associated injuries, and neurological status. Information from the ambulance attendant was included. Ninety-seven percent of thoracic and cardiac wounds were penetrating. An average of two chest tubes per patient were placed via the second and fifth intercostal spaces in the midaxillary line into either or both pleural cavities, depending on wound locations and x-ray fmdings. A pericardiocentesis was performed in certain cases," With resuscitation proceeding rapidly, the decision for defmitive treatment was guided by the following findings:
The Journal of
726
Zakharia
900
Thoracic and Cardiovascular Surgery
Table m. Evaluation of wounding agent to survival in cardiac wounds
en ~600 w
~
~
'"
::;: ~300
Fig. 4. Transportation distances of the 3,000 casualties.
1. The time lag since injury and the wounding history 2. The type of missile and wound sites 3. The depth of shock, its reponse to resuscitation, x-ray findings, and thoracostomy results 4. The presence of signs of life"? 5. The available logistics and options A short time lag allowed more persons with major thoracic and cardiac injuries to arrive alive. When decompensation occurred in the emergency room, despite active therapy, at least a cardiac tamponade was assumed. An urgent thoracotomy- 3. 5 in the emergency or preferably the operating room was rapidly performed. A left anterolateral thoracotomy with optional extension across the sternum was favored. Initial surgical correction included open relief of tamponade; control of cardiac perforation or major vessel bleeding by finger, suture, or clamp; and, when indicated, temporary clamping of the descending thoracic aorta.' Open cardiac resuscitation measures included manual massage, defibrillation, and bicarbonate, calcium, and inotropic drug infusions. Hemorrhage from the aorta, truncal vessels, or pulmonary hilum was controlled digitally and by clamping. For casualties who were dead on arrival with an unfavorable wounding history, resuscitation generally was not attempted.' In the group of patients undergoing thoracotomy in the emergency room,"" the best results were obtained in those in shock, in whom decompensation occurred after arrival in the hospital, and in whom the wounding history was favorable. A favorable wounding history consisted of a short retrieval time, a single wound caused by a low-velocitymissile fired from a long distance, and adequate life signs during transportation of the patient. The pivotal advantage of urgent thoracot-
Survived
--=
%
Shrapnel Gunshot Blast Blunt
159 120 3 3
56 42 I
72 I
1
2
84 60 33 66
Total
285
100
208
73
0: W
I
No.
Agent group
133
omy was hemorrhage control or cardiac resuscitation. Other benefits were the early diagnosis and repair of diaphragmatic, esophageal, and other wounds. In 27 casualties, the source of significant hemorrhage through the left tube thoracostomy was found at thoracotomy to be an injured spleen bleeding freely into the left pleural cavity via a ruptured diaphragm. Splenectomy was conveniently performed from the thoracic approach except in four patients, who required separate laparotomies for serious abdominal injuries. In 14 others, open thoracotomy showed the major right hemothorax to result from injuries of the diaphragm, liver, or hepatic or renal vessels. Repair was possible by extending to a thoracoabdominal incision in eight patients and by separate laparotomies in the remaining six. No anesthesia was required during urgent endotracheal intubation or the early part of open cardiac resuscitation. Survivors denied significant memory of these events. No preparation of the skin was performed in 55% of urgent thoracotomies. The skin was painted with preparatory solutions after successful operations, and no increase in wound infection was noted in this group. Total blood requirement in critically wounded patients varied from 4 to 70 units and averaged 12 units per patient, somewhat higher than in civilian injuries.' The hematocrit value of transfused blood units varied from 20% to 27%. The hematocrit value averaged 35% when drawn from family members and volunteers but only 24% when obtained from professional donors. Eighty percent of transfusion problems related to the latter source.
Results Cardiac IDJunes. The mean age was 18 years. High-velocity missiles such as the M15, M16, and Kalashnikov rifles caused small entrance wounds, wide internal cavitation effects, and major transverse "burning" damages. Gunshot wounds caused 42% of cardiac injuries, shrapnel 56%, and blast and blunt injuries 1% each (Table III). Cardiac wounds comprised 285 of the 1,992 thoracic
Volume 89
Battle injuries in Lebanon War
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May, 1985
Table IV. Clinical state and survival in cardiac
.
injuries 120
Clinical state or structure
Profound shock Mild shock or tamponade Mainly pericardiaI injury
%
87 188
53 146
Ul
61
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~
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Ul
80
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3
10
9
90
~ 60
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208
73
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~ 30
Table V. Distribution of 456 thoracic mixed injuries No. of casualties
Associated system
Thoraco-pcripheral vascular Thoraco-spinalcord Thoracocranial
55 21 9
Total
456
100
Thoraco-orthopedic
20
8
7
Table VI. Mortality in primarily thoracic casualties
Tube thoracostomy Resection Pulmonary hemorrhage Decortication Air leak Chest wall Esophagus Mammary jintercostals Great vessels Total
%
570 258 140 68 61 52 8 40 54 1,251
4 5 2 2 0 0 0 7
0.7 1.9 1.4 1.5 3.3 0 0 0 13.0
21
1.7
I
injuries, a 14% incidence, which is higher than the 3.3% incidence reported from World War 1I13 and the 2.8% incidence recorded in a report from Vietnam." The difference is probably related to special logistics in the Lebanon War. Prehospital mortality among cardiac injuries in World War II was reported at 84%15 and in major United States civilian reports, from 62% to 83%.2,9,16,17 We were unable to accurately assess the prehospital deaths since very few autopsies were performed. Cardiac survival statistics were influenced by early arrival of casualties, major weaponry, preparation of hospitals, and urgent surgical treatment. The overall survival rate in our 285 patients with cardiac wounds was 73% and includes all persons with
\
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~
o
Procedure/organ
\
I I I
10
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251 96 41 36 32
Thoracoabdominal
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THORACOTOMY 818 operations 54.5% Pulmonary resection 310 20.7% Control pulmonary hemorrhage 17011.3% Non pulmonary hemorrhage 112 7.5% 81 5.4% Decortication Major air leaks 73 4.9% Chest wall repair 62 4.1 % 10 0.7% Esophagus
Procedure and Frequency
Fig. 6. Analysis of 1,501 procedures for 1,251 casualties with primarily thoracic injuries.
cardiac injuries who arrived in emergency rooms with signs of life. A 60% survival rate was reported from World War 11,13 and Mattox and associates' reported a 67.5% survival rate in a group of civilians with severe gunshot wounds of the heart. Table IV shows survival relationships to clinical state. Cardiac wounds were multiple in 37 patients, with a survival rate of 51%. Fig. 5 shows the location of cardiac wounds with preponderance to the right ventricle and atrium, and the relationships to survival. Despite urgent surgical intervention in our series, the survival rate in persons with left ventricular wounds was 46%, and a clinical picture of pump failure was noted in 50%.
7 2 8 Zakharia
The causes of death in 80% of patients with cardiac injuries seemed directly related to the extent and complications of the cardiac wounds. Cardiac hemorrhage accounted for 30%, ventricular arrhythmias 12%, cerebral anoxia 18%, and noncardiac wounds 15%. Associated organ injuries were present in 88% of casualties. The organs most commonly injured were the lungs (68%), diaphragm (59%), liver (38%), and stomach (21%). Long-term folow-up confirmed the presence of relatively few sequelae, notably cardiac arrhythmias, psychological changes," interventricular dyskinesias, and postpericardiectomy syndrome. The removal of fragments and bullets was routinely attempted to reduce the need for secondary operations." Thoracic injuries. Tables II and V show the breakdown of thoracic casualties. Among 1,707 persons with thoracic noncardiac injuries, the central medical problem was the thoracic injury in 1,251 (73%). In the remaining 456 patients (27%), at least one nonthoracic organ was seriously injured. Ninety-seven percent of wounds were penetrating, caused by shrapnel (57%) and bullets (43%). Fig. 6 outlines the operations in the group with primary thoracic injuries. An average of 1.2 operations per patient was noted. In 45%, tube thoracostomy, with an average of two tubes per patient, was the definitive operative therapy. Appropriate techniques for this vital procedure have been emphasized elsewhere.19, 20 Prior to tube insertion, a gloved finger was passed through the thoracostomy incision to identify adhesions, lung collapse, diaphragmatic rupture, and visceral herniation into the chest. Three nonfatal technical complications from tube thoracostomy were noted. The average operative time in 818 thoracotomies was 104 minutes and the mean blood replacement, 1,350 mi. No demonstrable increase in mortality or morbidity was due to the technical procedure. An anterolateral approach was used in 50%, posterolateral in 44%, and midsternotomy in 6%. The choice of incision was guided by wound sites and clinical findings. Among 310 pulmonary resections, there were 162 segmental resections, 112 lobectomies, and 36 pneumonectomies. A frequent finding was a tom, semidetached pulmonary segment caused by a large-caliber missile or fragment, requiring completion resection and debridement. The mortality results are outlined in Table VI, the highest number of deaths (13%) resulting from great vessel injuries. These 54 patients, accounting for 4.3% of the primary thoracic group, influenced overall results. The mortality for all 1,251 thoracic patients excluding those with great vessel injuries was 1.2% and including those with vessel injuries, 1.7%. The mortality for open
The Journal of Thoracic and Cardiovascular Surgery
thoracotomy excluding great vessel injuries was 1.7% and including vessel injuries, 3.1%. The lowest mortality (0.7%) was in the 570 patients treated by tube thoracostomy. Of 73 thoracotomies for air leaks, plastic repair of the trachea or a major bronchus was done in 42% and suturing of smaller bronchial tears in 58%. Four of the eight esophageal penetrating injuries were diagnosed at early thoracotomy and the rest by nasogastric intubation and esophagography." The extent of esophageal injury was beyond simple suture repair in six." Because all were operated upon within hours of injury, there was no need for esophageal diversions or exclusions." Six perforations were in the lower third of the esophagus, and gastric patch onlays were successful in all." Pleural wraps were successful for the other two perforations in the middle esophagus. There were three anastomotic leaks with localized mediastinitis controlled by hydration and antibiotic therapy. Two persons with thoracic aortic injuries survived simultaneous resuscitation and operation as described elsewhere." Temporary cross-clamping of the descending aorta and application of a side-biting clamp to the perforated aorta preceded the repairs. Innominate vessel wounds were approached via the midsternotomy plus anterior thoracotomy book incision." Bypass grafts were employed in 78% and angioplastic repair in 28%. Injured thoracic veins were repaired when feasible. The mixed injuries are shown in Table V. Minor thoracic wounds were excluded. Mortality was 1.5 times greater in the group with thoracoabdominal wounds than in those with primary thoracic injuries, and the incidence of systemic complications and deep vein phlebitis was 2.7 times higher. Surgical priority was given to suspected cardiac and great vessel wounds, with special attention to the abdomen in lower thoracic wounds. The abdominal organs most frequently wounded were the liver (36%), stomach (31%), spleen (27%), and small intestines (24%). Diaphragmatic repair was routinely performed regardless of perforation size. There was no documentation of a repair disruption. Highvelocity missiles crossing the posterior mediastinum produced spinal cord injuries in seven patients despite absence of vertebral fractures. A burnlike effect with liquefaction of the spinal cord was found at laminectomy. There were 81 thoracic injuries in children under 12 years, an incidence of 4.7%. Penetrating wounds comprised 85%, blunt 13%, traumatic asphyxia 3%, and bum inhalation injuries 2%. Traumatic asphyxia resulted from chest wall compression by collapsed building walls; salvage by tube thoracostomy for hemopneumothorax along with intensive care measures was successful in all four children." Smoke from burning
Volume 89 Number 5 May, 1985
Table
Battle injuries in Lebanon War
729
vn. Mortality in 1,008 persons with nonthoracic vascular wounds Deaths Vessels
Femoral artery Femoral vein Femoral artery and vein Popliteal artery Popliteal vein Popliteal artery and vein Subclavian artery Subclavian vein Subclavian artery and vein Axillary artery Axillary vein Axillary artery and vein Brachial artery Abdominal aorta Inferior vena cava Abdominal aorta and inferior vena cava Renal artery Iliac artery Iliac vein Iliac artery and vein Common carotid artery Internal carotid artery External carotid artery Internal jugular vein Tibial artery Total
No. of patients
192 54 125 23 7 103 38 6 5 10 5 7 127 19 14 3 6 69 IS 21 15 52 22 10 60 1,008
homes caused serious inhalation bums in two children. Active pulmonary toilet, bronchoscopy, and bronchodilators were effective.28 Mortality in civilian reports for pediatric thoracic injuries varies from 7% to 14%.29.33 In this series five children died, an incidence of 6.2%. Two of the deaths were due to associated intra-abdominal wounds. Chylothorax in two children resulted from penetrating injuries to the left side of the chest. Supradiaphragmatic ligation with silk suture was successful in both. Mixed thoracoabdominal penetrating wounds were present in 45% of children. Complications in the 1,707 persons with thoracic injuries included atelectasis, minor chest tube complications, and surgical wound infection (0.5%). For pulmonary resections and tracheobronchoplasties, the incidence of bronchopleural fistula was 4%. Postoperative empyema was rare in patients operated upon promptly. However, in 17 casualties evacuated to the hospital weeks after thoracic injury, the incidence of empyema was 70%; four patients (24%) eventually required pleuropneumonectomies, the rest requiring multiple surgical procedures and prolonged hospitalizations. Air embolism was the apparent cause of death in two patients. Awareness of this condition was helpful in one
No. I
0 I 0 0 0 0 0 I 0 0
a a
I
%
0.5 0 1.0 0 0 0 0 0 20 0
a a a
12 7 2
63 50 67
13 2 6 2 3
19 13 29 13 3.8
a
a I
a 51
Vein association (%)
34 77
12 32
a
20
a
10
a
5.1
casualty in whom mild shock and cerebral signs were present. A head-down position, occlusion of the distal thoracic aorta, and cardiac massage to drive the air out of the coronary circulation probably contributed to his salvage." Special complications were noted in 60% of patients with thoracospinal injuries. These were bronchopneumonia, sepsis, recurrent urinary tract infection, bed sores, and wound dehiscence. Active psychiatric and social support was highly demanded in this subgroup of unfortunate patients. Vascular (nonthoracic) injuries. Excellent reviews of vascular injuries for World War II and the Korean and Vietnam conflicts were recorded by Elkin and DeBakey," DeBakey and Simeone," Hughes," and Rich, Baugh, and Hughes." Important and unique findings also observed in our study are summarized. Despite massive cavitary wounds formed by highvelocity missiles, the mortality and morbidity in extremity vascular wounds was low (Table VII). Unexpectedly, 50% of nonthoracic vascular injuries occurred in the femoral and popliteal areas, prime targets for rooftop professional snipers (Fig. 7). Concomitant deep vein injury was recorded in two thirds of patients with popliteal and one third of those with femoral and
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570
540510
504
480 450 (J)
UJ
~ ...J
:3
420 390 360
(J)
u
u,
o
300
a:: 270 UJ
~ 240
~ 210 180
150 120
99
90
60 30 Femoral Popliteal
Subclavian Brachial
Abdominal Aorta Iliac
Carotid
Tibial
Fig. 7. Analysis of nonthoracic vascular wounds sites (1,008 total wounds). axillary wounds. The popliteal nerve was injured in 40% of popliteal vessel wounds and bony fractures occurred in 22% of extremity injuries. Penetrating high-velocity missiles and fragments accounted for 97% of vessel wounds. Truncal injuries presented with hypovolemic shock, and extremity injuries presented with active bleeding or hematoma. Pulse deficits distal to the injured artery were noted in 85% and skeletal muscle ischemia was observed within 7 hours of injury. Arteriography, rarely used acutely (3%), was useful in false, arteriovenous aneurysms and long-standing vessel injuries. In 12 abdominal aortic wounds, death was directly caused by exsanguination and shock. Persons with suspected aortic injuries were operated upon urgently, with rapid exposure and manual compression applied, as proximal and distal control was attained. Aortic prosthetic grafts were used in two of seven salvaged patients. In four of eight patients dying of vena caval injuries, the injury involved the hepatic portion. Angioplastic repair or ligation was successful in seven persons with caval injuries. Carotid wounds were repaired by patch graft angioplasty (45%), prosthetic grafts (38%), and suture repairs (17%). An internal shunt was employed in 30%. Uneventful resection of 12 false carotid aneurysms was noted, with reversal of hemiparesis in six of eight patients operated upon for carotid-jugular communications. The extrathoracic subclavian vessels were uniformly
exposed by resection of the medial two thirds of the clavicle. Prosthetic grafts were employed in 70% of arterial wounds. Patch angioplasty or suture repair was used in 17 of 26 (65%) venous repairs. Ligation was employed in the remaining nine subclavian vein injuries, with arm edema persisting in two. One forearm amputation followed the resection of a massive false aneurysm of the axillary artery in a boy with hand ischemia referred 32 days after trauma. Vein grafts were preferred in axillary and brachial arterial repairs. An average of 1.7 vascular operations per patient was noted in 504 femoral and popliteal injuries. The saphenous vein was the preferred conduit, used in 72%. Direct suture of the ruptured artery was abandoned very early, and deep vein reconstruction was routinely attempted. When deep vein ligation was mandatory, a long fasciotomy was performed. Distal vessel irrigation with heparinized saline and final Fogarty catheter evacuations were undertaken routinely. Fracture stabilization was done by internal fixation (31%), skeletal traction (54%), and bivalved casts (15%). One patient developed gas gangrene 18 hours after reconstruction of the femoral artery and died despite amputation and active treatment. The metabolic syndrome" in various forms of severity was noted in 16 patients and may have accounted for three deaths. There were 49 patients with massive femoral or popliteal injuries who required at least six vascular procedures, with 95% limb salvage. The incidence of amputations was highest in popliteal wounds (6%),
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followed by femoral wounds (1.3%). Popliteal nerve reconstruction was performed at the same time as vascular repair, by logistic necessity, in 70% and after 6 weeks in 30%. No significant differences in results for the two groups was noted, and chronic nerve problems persisted in 40%.
Discussion The incessant barrage of modem high-velocity missiles and rockets fired at close ranges resulted in extensive cardiovascular and thoracic injuries. Rapid patient retrieval mandated effective resuscitation and urgent surgical control. The availability of blood, the young age group, and the active compassion for the wounded were favorable. The highest personal daily count was 11 major specialty operations. As technical proficiency in surgical exposures and corrections developed, operative time was reduced and salvage significantly improved. Only minor differences in results were documented when operations were performed during active battle conditions with stringent operating facilities. Among 3,000 casualties in this study, the highest mortality rates were among those with cardiac, aortoiliac,and thoracic great vessel injuries: Hemorrhage was the most frequent underlying cause of death and cardiac rupture the second. The specialized cardiovascular and thoracic center provided the following advantages: 1. A central unit for early treatment of specialty injuries 2. Updated equipment including cardiopulmonary bypass andautotransfusion pumps 3. Underground adjacent emergency operating and radiology suites within direct reach of ambulances In cardiac wounds, predetermined factors influenced ultimate survival. One was the proximity, multiplicity, and type of firing agents. Another was dampening of missiles during their initial passage through walls, special clothing, sternum, ribs, scapula, or the arm. The site of cardiac injury was relevant, left ventricular wounds being the most deadly,' followed by multiple cardiac wounds, and those of the posterior wall. In the last group, one limiting factor during operations was the frequency of ventricular fibrillation upon lifting of the heart for exposure.' Fifty percent of patients dying of left ventricular wounds had pump failure resistant to pharmacologic support. We believe that mechanical cardiac support could prove valuable in such selected patients. Most cardiac lacerations were repaired with pledget-
reinforced mattress sutures. Bleeding coronary vessels were suture ligated in seven patients and suture repaired in two others." No clinical sequelae were noted on follow-up of all nine patients, although stable electrocardiographic changes were present in five. In thoracic injuries, the principles of treatment of open pneumothorax, paradoxical chest motion, tension pneumothorax, and sucking wounds all have been well described elsewhere.":" Fifty-five percent of patients with primarily thoracic injuries underwent open thoracotomy, a greater incidence than in civilian reports."" Tube thoracostomies were the definitive operation in patients with milder injuries, and the mortality was 0.7%. When cardiac and great vessel injuries are excluded, the mortality among thoracotomy patients (681) was only 1.7%. Thoracotomy, also effective in reducing ventilatory deaths in bronchopulmonary injuries, if proficiently performed, has comparable safety in a military setting. The indications for thoracotomy were well documented elsewhere. 19,34.42.43,45,46 In the Lebanon battles, special factors made early thoracotomy a choice option. Serious personnel, diagnostic, and equipment shortages reduced the validity of Conservative approaches." A modem variety of military weapons causing extensive wounds, with significant blood loss and shock in young patients, mandated secure open surgical control. Open thoracotomy allows effective control of hemorrhage, major air leaks, treatment of pulmonary rupture, decortication, and debridement. Diaphragmatic'>" and esophageal": 22, 50 injuries are confirmed and treated before complications of delay set in. The same applies for relief of cardiac tamponade" and the removal of bullets and fragments when proximal to vessels, esophagus, or trachea." Mixed thoracic injuries carried a 50% higher mortality. Increased complications were notable among associated spinal cord injuries. In thoracic abdominal injuries, life-threatening hemorrhage in both cavities necessitated simultaneous surgical control, with abdominal priority in some." In children special critieria were strictly applied. These included rapid correction of hypovolemia before shock occurred, early thoracostomy to correct or prevent shifts of the freely mobile mediastinum, nasogastric intubation for aerophagia, and urgent thoracotomy whenever indicated. The low mortality also reflected persistence in treatment. The relative inadequacy of arterial suture repairs and end-to-end arterial reconstruction for high-velocity missile wounds was evidenced by a 42% incidence of
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disruption with such methods early in our experience. Suture line disruptions, heralded by sudden hemorrhage or pulsatile hematoma bulging under the skin closure, occurred most frequently on the sixth postoperative day (56%). The arterial wall was notably edematous with partial necrosis of the suture line. Cultures or smears were positive in 30%. We found subintimal arterial wall damage to extend beyond the apparent rupture proximally and distally for an average total distance of 8 cm. To ensure success of the secondary bypass procedure, we constructed the proximal and distal anastomoses at least 10 em from either direction of the necrosed suture line. A less radical approach was rarely successful. Persistence in limb revascularization in young patients is essential and rewarding. One such patient underwent eight femoral-popliteal vascular operations within 2 months with excellent results. Wound management included radical debridement and cavitary hemostasis. The subcutaneous tissue was left open in 40%, and secondary closure was performed around the third postoperative day. The contralateral saphenous vein was the preferred bypass conduit for combined arterial and deep vein wounds. Deep vein repairs were routinely attempted, but when ligated by necessity, a simultaneous distal fasciotomy was performed. Embolectomy was the most common secondary operation, performed in 18%. Lumbar sympathectomy for causalgia produced favorable results in selected patients with popliteal arterial problems. Chronic neurological signs and symptoms were common in popliteal triad injuries, whether primary or secondary nerve repair was performed. After angiographic delineation, arteriovenous aneurysms or communications were approached by ligating and dividing the layers of distended superficial veins. Proximal and distal control of the involved vessels usually was easy and the fistula was divided. Arterial repair was performed by angioplasty or by interposition of a prosthesis or vein graft. False aneurysms can reach huge sizes, at times precluding adequate proximal and distal control. I found it safe and expedient to approach extrathoracic aneurysms directly. With proper timing, the false hematoma can be rapidly removed and the arterial tear directly exposed and digitally controlled. Removal of the hematoma now allows excellent proximal and distal arterial control and reconstruction of the vessel. This approach is not appropriate for intrathoracic vascular aneurysms. I am grateful to Drs. M. E. DeBakey, F. A. Simeone, R. Hopkins, and J. Jude for their helpful personal communications since 1978 which guided this project.
Surgery
REFERENCES Zakharia AT: Cardiovascular and thoracic trauma center. Archives of the Arab Research Center for Injuries, 1977, Beirut, Lebanon 2 Sugg WL, Rea WJ, Ecker RR, Webb WR, Rose EF, Shaw RR: Penetrating wounds of the heart. An analysis of 459 cases. J THORAC CARDIOVASC SURG 56:531-545, 1968 3 Mattox KL, Beall AC Jr, Jordan GL, DeBakey ME: Cardiorrhaphy in the emergency center. J THORAC CARDIOVASC SURG 68:886-895, 1974 4 Bodai BI, Smith JP, Ward RE, O'Neill MB, Auburg R: Emergency thoracotomy in the management of trauma. JAMA 249:1891-1896,1983 5 Rohman M, Ivatury RR, Steichen FM, Gaudino J, Nallathambi MN, Khan M, Stahl WM: Emergency room thoracotomy for penetrating cardiac injuries. J Trauma 23:570-576, 1983 6 Baker CC, Thomas AN, Trunkey DD: The role of emergency room thoracotomy in trauma. J Trauma 20:848-855, 1980 7 Flynn TC, Ware RE, Miller PW: Emergency room thoracotomy. Ann Emerg Med 11:413-416, 1982 8 Knott-Craig CJ, Przybojewski JZ, Barnard PM: Penetrating wounds of the heart and great vessels. A new therapeutic approach. S Afr Med J 62:316-320, 1982 9 Beall AL, Ochsner JL, Morris GC Jr, Cooley DA, DeBakey ME: Penetrating wounds of the heart. J Trauma 1:195-207, 1961 10 Steichen FM, Dargan EL, Efron G, Pearlman DM, Weil PH: A graded approach to the management of penetrating wounds to the heart. Arch Surg 103:574-580, 1971 11 Hardy JD, Williams RD: Penetrating heart wounds. Analysis of 12 consecutive cases individualized without mortality. Ann Surg 166:228-231, 1967 12 Carrasqvilla C, Wilson RE, Wait AJ, Arbulu A: Gunshot wounds of the heart. Ann Thorac Surg 13:208-213, 1972 13 Berry FF, ed.: Surgery in World War II, Thoracic Surgery, Office of the Surgeon General, Department of the Army, Vol 1, 1963, Vol. II, 1965 14 Gielchinsky I, McNamara JJ: Cardiac wounds at a military evacuation hospital in Vietnam. J THORAC CARDIOVASC SURG 60:603-606, 1970 15 Parmly LF, Mattingly TW, Manion WM: Penetrating wounds of the heart and aorta. Circulation 17:953-973, 1958 16 Maynard AL, Brooks HA, Froix GJ: Penetrating wounds of the heart. Arch Surg 90:680-686, 1965 17 Boyd JS, Streider JW: Immediate surgery for traumatic heart disease. J THORAC CARDIOVASC SURG 50:305-315, 1965 18 Abbot JA, Cousineau M, Chetlin M, Thomas AN, Lim RC Jr: Late sequelae of penetrating cardiac wounds. J THORAC CARDIOVASC SURG 75:510-518, 1975 19 Bonnabeau RC: Penetrating thoracic trauma. Minn Med 57:270-278, 1974
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20 Millikan JS, Moore EE, Steiner E: Complications of tube thoracostomy for acute trauma. Am J Surg 140:738-741, 1980 21 Schein M, Pool R, Conlan AA: Late management of penetrating oesophageal injury. S Afr Med J 63:456-458, 1983 22 Symbas PN, Hatcher CR, Vlasis SE: Esophageal gunshot wounds injuries. Ann Surg 191:703-707, 1980 23 Urschel HC, Razzuk MA, Wood RE, Galbraith N, Pockey M, Paulson DL: Improved management of esophageal perforation. Exclusion and diversion in continuity. Ann Surg 179:587-591, 1974 24 Robinson JC, Isa SS, Spees EK: Substernal gastric bypass for palliation of esopheageal carcinoma. Rationale and technique. Surgery 91:305-311,1982 25 Reul GJ, Beall AC Jr, Jordan GL, Mattox KL: The early operative management of injuries to the great vessels. Surgery 74:862-873, 1973 26 Graham JM, Feliciano DV, Mattox KL, Beall AC, DeBakey ME: Management of subclavian vascular injuries. J Trauma 20:537-544, 1980 27 Jones J: The management of traumatic asphyxia. Case report and literature review. J Trauma 16:235-238, 1976 28 Moylan JA: Smoke inhalation and burn injury. Surg Clin North Am 60: 1533-1540, 1980 29 Erchelberger MR, Randolph JG: Thoracic trauma in children. Surg Clin North Am 61:1181-1197, 1981 30 Mayer T, Matlak M, Johnson J, Walker ML: The modified injury severity scale in pediatric multiple trauma patients. J Pediatr Surg 15:719-726, 1980 31 Sinclair MC, Moore T: Major surgery for abdominal and thoracic trauma in childhood and adolescence. J Pediatr Surg 9:155-162,1974 32 Smyth BT: Chest trauma in children. J Pediatr Surg 14:41-47, 1979 33 Welch KJ: Thoracic injuries, The Injured Child, JG Randolph et ai, eds., Chicago, 1980, Year Book Medical Publishers, Inc., pp 213-215 34 Thomas AN: Penetrating thoracic trauma (Trauma Rounds). West J Med 121:510-514, 1974 35 Elkin DC, DeBakey ME: Surgery in Wolrd War II, Vascular Surgery, Washington, D. C; 1955, Office of the Surgeon General, Department of the Army
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36 DeBakey ME, Simeone FA: Battle injuries of arteries in World War II. An analysis of 2,471 cases. Ann Surg 123:534-579, 1946 37 Hughes CW: Acute vascular trauma in Korean War casualties. An analysis of 180 cases. Surg Gynecol Obstet 99:91-100, 1954 38 Rich NM, Baugh JH, Hughes CW: Acute arterial injuries in Vietnam: 1,000 cases. J Trauma 10:359-368, 1970 39 Haimovici H: Metabolic syndrome secondary to acute arterial occlusions, Vascular Emergencies, H Haimovici, ed., New York, 1982, Appleton-Century-Crofts, pp 267289 40 Espada R, Whisennand HH, Mattox KL, Beall AC Jr: Surgical management of penetrating injuries of the coronary arteries. Surgery 78: 755-760, 1975 41 Lewis FR: Thoracic trauma. Surg Clin North Am 62:97103, 1982 42 Webb WR: Thoracic trauma. Surg Clin North Am 54:1179-1192, 1974 43 Richardson JD: Management of noncardiac thoracic trauma. Heart Lung 7:286-292, 1978 44 Hughes R: Thoracic trauma. Surg Clin North Am 48:759- 771, 1968 45 Tayos MS, Guzman DD: Management of 115 cases of thoracic trauma. Emphasis on 44 penetrating injuries. JAMA 43:267-283, 1967 46 Blalock JB, Ochsner JL: Management of thoracic trauma. Surg Clin North Am 46:1513-1524, 1966 47 Estrera AS, Platt MR, Mills LJ: Traumatic injuries of the diaphragm. Chest 75:306-313, 1979 48 Wise L, Connors J, Hwang YH: Traumatic injuries to the diaphragm. J Trauma 13:946-950, 1973 49 Sterns LP, Jensen NK, Schmidt WR: Diaphragmatic disruption in major thoracic trauma. A review of 16 cases. Can J Surg 12:426-431, 1969 50 Michel L, Grillo HC, Malt RA: Operative and nonoperative management of esophageal perforations. Ann Surg 194:57-63, 1981 51 Turney SZ, Attar S, Ayella R, Cowley RA, McLaughlin J: Traumatic rupture of the aorta. A five-year experience. J THoRAc CARDIOVASC SURG 72:727-734, 1976