Clinical Challenges in Trauma Surgery: Stabbed in the Back - Decision Making in a Penetrating Junctional Vascular Injury

“It’s 5pm and your Consultant (attending) has headed off home. A patient arrives in the resuscitation room blood spurting from a stab wound in the armpit. Join Roisin – a junior Major Trauma fellow, Prash – a surgical trainee, Max – a senior trauma surgery fellow, and Chris – a Consultant trauma surgeon, as we talk through decision making from point of injury to aftercare in this challenging trauma surgical case”.

• Hosts: Bulleted list of host names, including title, institution, & social media handles if indicated
1. Mr Prashanth Ramaraj. General Surgery trainee, Edinburgh rotation. @LonTraumaSchool
2. Dr Roisin Kelly. Major Trauma Junior Clinical Fellow, Royal London Hospital.
3. Mr Max Marsden. Resuscitative Major Trauma Fellow, Royal London Hospital. @maxmarsden83
4. Mr Christopher Aylwin. Consultant Trauma & Vascular Surgeon and Co-Programme Director MSc Trauma Sciences at Queen Mary University of London. @cjaylwin

• Learning objectives: Bulleted list of learning objectives.
A) To become familiar with prehospital methods of haemorrhage control in penetrating junctional injuries.
B) To recognise the benefits of prehospital blood product resuscitation in some trauma patients.
C) To follow the nuanced decision making in decision for CT scan in a patient with a penetrating junctional injury.
D) To describe the possible approaches to the axillary artery in the context of resuscitative trauma surgery.
E) To become familiar with decision making around intraoperative systemic anticoagulation in the trauma patient.
F) To become familiar with decision making on type of repair and graft material in vascular trauma.
G) To recognise the team approach in holistic trauma care through the continuum of trauma care.

• References: Bulleted list of references with PubMed links.

1. Perkins Z. et al., 2012. Epidemiology and Outcome of Vascular Trauma at a British Major Trauma Centre. EJVES. https://www.ejves.com/article/S1078-5884(12)00337-1/fulltext
2. Ramaraj P., et al. 2025. The anatomical distribution of penetrating junctional injuries and their resource implications: A retrospective cohort study. Injury. https://www.injuryjournal.com/article/S0020-1383(24)00771-X/
3. Smith, S., et al. 2019. The effectiveness of junctional tourniquets: A systematic review and meta-analysis. J Trauma Acute Care Surg. https://journals.lww.com/jtrauma/abstract/2019/03000/the_effectiveness_of_junctional_tourniquets__a.20.aspx
4. Rijnhout TWH, et al. 2019. Is prehospital blood transfusion effective and safe in haemorrhagic trauma patients? A systematic review and meta-analysis. Injury. https://www.injuryjournal.com/article/S0020-1383(19)30133-0/
5. Davenport R, et al. 2023. Prehospital blood transfusion: Can we agree on a standardised approach? Injury. https://www.injuryjournal.com/article/S0020-1383(22)00915-9.
6. Borgman MA., et al. 2007. The Ratio of Blood Products Transfused Affects Mortality in Patients Receiving Massive Transfusions at a Combat Support Hospital. J Trauma Acute Care Surg. https://journals.lww.com/jtrauma/fulltext/2007/10000/the_ratio_of_blood_products_transfused_affects.13.aspx
7. Holcomb JB., et al. 2013. The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study. Comparative Effectiveness of a Time-Varying Treatment With Competing Risks. JAMA Surgery. https://jamanetwork.com/journals/jamasurgery/fullarticle/1379768
8. Holcomb JB, et al. 2015. Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma. The PROPPR Randomized Clinical Trial. JAMA. https://jamanetwork.com/journals/jama/fullarticle/2107789
9. Davenport R., et al. 2023. Early and Empirical High-Dose Cryoprecipitate for Hemorrhage After Traumatic Injury. The CRYOSTAT-2 Randomized Clinical Trial. JAMA. https://jamanetwork.com/journals/jama/fullarticle/2810756
10. Baksaas-Aasen K., et al. 2020. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial. ICM. https://link.springer.com/article/10.1007/s00134-020-06266-1
11. Wahlgren CM., et al. 2025. European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular Trauma. EJVES. https://esvs.org/wp-content/uploads/2025/01/2025-Vascular-Trauma-Guidelines.pdf
12. Khan S., et al. 2020. A meta-analysis on anticoagulation after vascular trauma. Eur J Traum Emerg Surg. https://link.springer.com/article/10.1007/s00068-020-01321-4
13. Stonko DP., et al. 2022. Postoperative antiplatelet and/or anticoagulation use does not impact complication or reintervention rates after vein repair of arterial injury: A PROOVIT study. Vascular. https://journals.sagepub.com/doi/10.1177/17085381221082371?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.
If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listen
Behind the Knife Premium:
General Surgery Oral Board Review Course: https://behindtheknife.org/premium/general-surgery-oral-board-review
Trauma Surgery Video Atlas: https://behindtheknife.org/premium/trauma-surgery-video-atlas
Dominate Surgery: A High-Yield Guide to Your Surgery Clerkship: https://behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkship
Dominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotation
Vascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-audio-review
Colorectal Surgery Oral Board Review Course: https://behindtheknife.org/premium/colorectal-surgery-oral-board-audio-review
Surgical Oncology Oral Board Review Course: https://behindtheknife.org/premium/surgical-oncology-oral-board-audio-review
Cardiothoracic Oral Board Review Course: https://behindtheknife.org/premium/cardiothoracic-surgery-oral-board-audio-review
Download our App:
Apple App Store: https://apps.apple.com/us/app/behind-the-knife/id1672420049
Android/Google Play: https://play.google.com/store/apps/details?id=com.btk.app&hl=en_US