PVSS13. Characterization and Management of Cervical Vascular Injuries Resulting from Improvised Explosive Devices (IEDs) and Rocket Propelled Grenades (RPGs)

Improvised explosive devices (IEDs) and rocket propelled grenades (RPGs) encountered in combat situations cause a unique pattern of injuries unlike that seen in civilian trauma. The purpose of this study was to characterize the presentation, diagnosis and management of vascular injuries caused by these multiple high velocity fragments in the neck, an area not usually protected by personal body armor. The trauma registry of evacuated soldiers injured in combat from January 1, 2006 to June 30, 2010 was reviewed for penetrating injuries to all zones of the neck deep to the platysma caused by IEDs and RPGs. All vascular injuries, diagnostic studies utilized, repairs performed, negative explorations and final results were identified. A total of 252 medical records were identified, 53 were excluded, leaving 199 patients. Thirty eight patients (19.1%) with 44 vascular injuries were seen. Arterial injuries included: common carotid- 2, internal-7, external-9, vertebral-4, and subclavian-3. Venous injuries were: internal jugular-15, external jugular-4 Procedures included primary repair in 9, ligation in 21, bypass in 4 (3 vein, 1 prosthetic), and endovascular repair in 2. Eight were treated with anticoagulation alone. Eleven patients underwent surgery based on physical exam alone, 27 had pre-procedural CT scans. There were 55 negative neck explorations, 37 based on proximity alone, 4 for bleeding, 4 for CT abnormalities and 10 for associated injuries. One venous injury requiring ligation had a normal PE and CT. One stroke occurred and no patient that reached a tertiary level of care died from their neck injuries. Explosive devices involving the neck cause significant vascular injuries over 20% of cases. Approximately 30% are evident of PE alone; nearly all others are identified by CT. Proximity alone on PE or CT does not warrant neck explorations even in combat conditions. Standard open repairs successfully treat these injuries.