Asia: Sri Lanka





Key Words:

vascular trauma , fasciotomy , ischemia time , reperfusion injury

 




Introduction


Sri Lanka has emerged from a 30-year-long civil war that commenced in 1983. A group calling themselves Liberation Tigers of Tamil Eelam (LTTE) fought the governmental forces of Sri Lanka for a separate state in the north and east parts of the country. A feature of this conflict was the large number of patients with penetrating vascular injuries from mortars and T56 gunshots, in addition to frequent bomb blasts and suicide-bomb attacks that were carried out mainly in Colombo, the country’s capital, and in the rest of the country.


The challenges to the vascular surgeons/services in the country during this period were numerous. The conflict produced combatant injuries caused by bullets, grenades, shells and anti-personal mines. Civilian injuries as a consequence of the conflict were those caused by bomb blasts and suicide bombers. These injuries were in addition to the preexisting civilian vascular workload from vehicular accidents and conflicts ending in stab injuries and low-velocity gunshots. A unique type of injury specific to the country is the “trap gun” injury ( Fig. 26-1 ), which is caused by a homemade device consisting of a loaded shotgun or a length of metal pipe loaded with gunpowder with a kneehigh cord attached to the trigger and tied to a tree stump. The intention of farmers is to ward off wild animals like wild boar from foraging and destroying their crops. Humans unknowingly walk across the path, pull on the trip wire, and set off the trigger, shooting themselves around the knee.




FIGURE 26-1


Trap gun, which is an improvised homemade shotgun.

(Courtesy Mahanama Gunasekara.)


Finally, as the number and complexity of endovascular interventions grow, there has been an increase in the number of access site pseudoaneurysms, presenting further challenges.




Epidemiology


The military campaign was characterized by phases of intense conflict to times of relative lull. An incidence of 2.2% of vascular injuries in 5821 injured security personnel was reported during a 6-month period of combat from December 2008 to June 2009. Rifle bullets and high-velocity fragments were the causes of most injuries, the majority affecting the distal half of lower extremities, the popliteal vessels being involved in 34% of the instances.


In the civilian setting, in a study from a tertiary-care center, out of a total of 1500 admissions, 70 (4.6%) patients had a total of 81 vascular injuries. 46% of these injuries were war related, with 41% due to high-energy blasts from artillery shells, mortars, rocket-propelled grenades, high-explosive bombs, and antipersonnel mines. Civilian conflicts that resulted in vascular injuries were caused by stab injuries (26%) and gunshots (17%) that included high-velocity rifles, machine guns, low-velocity shotguns, and trap guns. Vehicular accidents, industrial accidents, and iatrogenic trauma accounted for the balance of 33% of the cases ( Figs. 26-1, 26-2, and 26-3 ). In another urban setting, 77 patients with trap gun injuries were consecutively admitted to this hospital during a 5-month period.




FIGURE 26-2


Anatomical distribution and types of repair of 128 combatants who sustained military vascular trauma.

Iry, Primary; IPVG, interposition vein graft.



FIGURE 26-3


Mode of vascular injury in 81 consecutive injuries at a civilian center.




Systems of Care and Transport


The Sri Lankan Army medical corps has organized its casualty care structure into three lines categorized as first, second, and third lines of care depending on the distance from the front line, the available resources, and the casualty handling capability.


First Line of Care


The first line of care is sited very close to the front line for provision of basic casualty care immediately after injury. This primary care includes arrest of bleeding, establishment of intravenous access, pain relief, and fracture immobilization. There was a variety of types of tourniquets used, including a piece of twinned cloth to less-sophisticated military tourniquets consisting of a belt and buckle ( Fig. 26-4 ). Standard modern tourniquets were unavailable. The use of the former varieties of tourniquets was a lifesaving rather than a limb-saving exercise. Occasionally the lag time to reach a center for definitive vascular reconstruction was short enough to salvage the limb. The authors introduced intelligent packing to effectively control bleeding, replacing these tourniquets, while preserving collateral circulation to keep the limb viable.




FIGURE 26-4


Types of repair in 81 consecutive injuries at a civilian center.

PTEF, Polytetrafluoroethylene.


Second Line of Care


The second line of care consisted of the advance dressing station (ADS), the main dressing station (MDS), and field hospitals.


The ADS was sited close to three regimental aid points, sited 400 meters to 5 kilometers from the front line. It was manned by a single medical officer, two nurses, and three nurse assistants and was capable of emergency combat resuscitation, including intubation, chest-drain insertion, arrest of bleeding, and intravenous infusion of crystalloids.


Each MDS was sited close to 3 ADSs with the capability of stabilizing and airlifting casualties to specific care facilities. It was manned by one senior medical officer, four nurses, six nurse assistants, and other supportive care personnel. Staff at the MDS had the capacity to transfuse uncross matched group O blood and to perform basic lifesaving surgical procedures such as tracheotomies, amputations, and wound exploration to achieve hemostasis.


Third Line of Care


The third line of care is the tertiary military base hospitals and general hospitals capable of definitive surgical care with specialized services that included vascular, cardiothoracic, and neurosurgical services supported by intensive care unit facilities.


In 2008-2009, the military base hospital (MBH) Anuradhapura, situated 180 kilometers from the conflict zone, was converted into a center for definitive extremity vascular care. General surgeons trained in vascular surgery were deployed to this hospital to minimize the delay to revascularization. The MBH was equipped with two operating theaters, a three-bed intensive care room, and an 80-bed ward ( Fig. 26-5 ).




FIGURE 26-5


(A, B, C) The military base hospital (MBH) Anuradhapura.


The civilian setting remains poorly organized. Prehospital care with ambulances is available in a few cities such as Colombo (the capital city) and Galle (a large city on the southern coast of the island). In Colombo and Galle, fire fighters and hospital ambulance staff, respectively, were trained and certified in prehospital care. However, the most common response to injury in Sri Lanka is the “scoop and run” method. Readily available transport facilities are commandeered to rush patients to hospitals, and these are often vans or the ubiquitous three-wheeler (also known as a “trishaw” or “tuk-tuk”), open-passenger transport vehicles. Patients are bundled into these small vehicles with little or no attention to the type, extent, and severity of injuries ( Fig. 26-6 ). Unlike the military system where discipline is a premium factor, the civilian system suffers from a lack of protocols. The quality of care given at first-contact hospitals, which are manned by medical officers or general surgeons, depends on many factors. Diagnostic acumen depends on the medical-school experience of the first contact doctor because only a minority of medical teaching hospitals provides a vascular service. The probability of the general surgeon attending to a vascular injury depends on his postgraduate training, commitment, and the workload in general. Thus most patients with a vascular injury are transferred to one of two vascular centers in Colombo or Kandy. In a study of 134 patients treated for extremity vascular trauma over a 9-month period, it was found that initiating wound débridement in the field contributed to significantly lower postoperative complication rates. The authors recommend pretransfer care consisting of early wound débridement, arrest of bleeding, and four-compartment fasciotomy. Compliance with such a protocol is unpredictable and generally poor, and there is no method to enforce this. Furthermore, in the case of mass casualties, it may not be possible for a single surgeon to deliver even basic care. In such instances, triage and transfer as quickly as possible to a tertiary-care center is the standard practice.




FIGURE 26-6


The trishaw (also known as a “tuk-tuk” or “three-wheeler”) is a common mode of casualty transport in Sri Lanka.


The use of temporary shunts in such a peripheral setting is contentious. Inexperienced surgeons using improvised shunts (i.e., pieces of cut, sterile, intravenous set tubing) that may damage the intima of adjacent healthy artery, causing dissection and promoting thrombosis, is a serious concern. On the other hand the author, a vascular surgeon, used temporary shunts successfully to buy time in instances where several patients with limbs dying from vascular injuries arrived at one hospital at the same time.




First Line of Care


The first line of care is sited very close to the front line for provision of basic casualty care immediately after injury. This primary care includes arrest of bleeding, establishment of intravenous access, pain relief, and fracture immobilization. There was a variety of types of tourniquets used, including a piece of twinned cloth to less-sophisticated military tourniquets consisting of a belt and buckle ( Fig. 26-4 ). Standard modern tourniquets were unavailable. The use of the former varieties of tourniquets was a lifesaving rather than a limb-saving exercise. Occasionally the lag time to reach a center for definitive vascular reconstruction was short enough to salvage the limb. The authors introduced intelligent packing to effectively control bleeding, replacing these tourniquets, while preserving collateral circulation to keep the limb viable.


Oct 11, 2019 | Posted by in CARDIOLOGY | Comments Off on Asia: Sri Lanka
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