6. Type of injury
• (1) intimal injuries (flaps, disruptions, or
subintimal/ intramural hematomas);
• (2) complete wall defects with
pseudoaneurysms or hemorrhage;
• (3) complete transections with hemorrhage or
occlusion;
• (4) arteriovenous fistulas; and
• (5) spasm
7. Type
• (1) intimal injuries
(flaps, disruptions, or
subintimal/ intramural
hematomas);
12. Hard sign
– Active pulsatile haemorrhage
– Pulsatile or expanding haematoma
– Sign of limb ischaemia
• 5ps
– Diminished or absent pulse
– Bruit and thrill
16. Magnetic Resonance Angiography
• MRA has the advantage of not requiring
iodinated contrast agents to provide vessel
opacification
• Gadolinium is used as a contrast agent for
MRA studies, and as it is generally not
nephrotoxic, it can be used in patients with
elevated creatinine.
20. Neck injury classification
• Zone I: base of neck, thoracic outlet to 1cm
above clavicle .
• Zone II : 1 cm above clavicle
to
angle of jaw
• Zone III : above angle of
mandible
21. Neck
•
•
•
•
•
Zone I and III are difficult to assess
Image the stable patient
Mandatory exploration unstable patient
Exclude :
Associated injuries on the
– cervical spine,
– airway, and
– digestive tract
22. Management guideline
• 1. Immediate operation is indicated for unstable patients with
active bleeding not responsive to vigorous resuscitation or with
rapidly expanding hematoma or airway obstruction, irrespective
• of anatomical zone.
• 2. Injuries in zone II not penetrating the platysma need no further
examination.
• 3. All others require further diagnostic evaluation with
angiography, duplex ultrasound, and CT to determine whether
critical structures have been injured.
• If angiography or high-quality duplex ultrasound is not available,
injuries in zone II need to be surgically explored
23. Neck exposure
•
•
•
•
•
•
•
Venous injuries exploration of a neck injury can be treated either
by repair using simple or running sutures or by ligation.
In bilateral injuries to the
internal jugular veins, however,
reconstruction of one of the sides
is indicated to avoid
severe venous hypertension.
26. Chest
Indication for thoracotomy
• Penetrating unstable, unresponsive to resuscitation
• Chest tube
• Deterioration of vital signs when the drain is started
• 1.500–2.000 ml of blood within the first 4–8 h
• Drainage of blood exceeding 300 ml/h for more than
4h
• More than half of pleural cavity filled with blood on
x-ray despite a well functioning chest tube
27. Aorta
• Usually results from
deceleration injury-fatal
unless false aneurysm
develops in mediastinum
Back pain, hypotension;
systolic murmur or
signs of tamponade
in some cases; characteristic
31. Approach to Chest
• Posterolateral thoracotomy
• Median sternotomy
• Anterolateral (4th)
32. Rupture of aorta
• widening of mediastinum on chest X-ray;
diagnosis confirmed by arteriography
• Urgent thoracotomy and Dacron graft or
minimal-access stent graft if available
33. Rates
• Major abdominal vascular injury is seen in up to 25% of
patients admitted with vascular trauma.
• Blunt trauma/penetrating trauma.
• Abdominal injury represents 10–20% of all traumas to the
body caused by road traffic accidents.
• Major vascular injury is estimated to occur in about 10% of
cases of penetrating stab wounds in the abdomen
• and in about 25% of gunshot wounds.
• Blunt abdominal trauma affects major vessels less frequently,
estimates of below 5% is common in the literature
34. Abdomen
• Aorta and its branches,
• IVC, portal and iliac veins
– Indication for laparotomy
– Damage control
– Re-explore
– Control bleeding
– Avoid prosthesis
35. Abdomen
• Contron
– Supra diaphragmatic
– Supr-celiac
– Infra-renal
– Ballon, occlusion
• Exposure
– From the left
– From the right
36. Boundaries of the Retroperitoneal Region
• Above: T12 and 12th rib
• Below: Base of the sacrum, the iliac crest, the
upper rami of the pubic bones, and the pelvic
diaphragm
• Anterior: parietal peritoneum of the
retroperitoneal space, part of the liver and its
bare area, part of the duodenum, part of the
ascending colon, part of the descending colon,
and much of the pancreas within the lesser
sac.
37. ZONES
• Zone I (centromedial)
• Upper: Diaphragmatic, esophageal, and
aortic openings
• Lower: Sacral promontories
• Lateral: Psoas muscles
• Contents: Abdominal aorta, inferior vena cava,
pancreas, duodenum (partial) .
38. Zone II (lateral)
•
•
•
•
Upper: Diaphragm
Lower: Iliac crests
Lateral: Psoas muscles
Contents: Kidneys and their vessels, ureters
and their abdominal parts, ascending and
descending colon, hepatic and splenic flexure
39. Zone III (pelvic)
• Anterior: Space of Retzius (symphysis pubis
and pubic bones, separated from the bladder
by the space of Retzius)
• Posterior: Sacrum
• Lateral: Bony pelvis
• Contents: Pelvis in content, pelvic wall,
rectosigmoid colon, iliac vessels, urogenital
organs (partial)
41. Therapeutic Implications of
Retroperitoneal Zones
• •Zone I: highest risk of vascular injury. Investigate with
surgery unless small and stable.
• •Zone II: second most common site of retroperitoneal
hemorrhage, predominantly renal injuries.
• •Penetrating: selective •Exploration or angiographic
embolization
• •Blunt: Observation and follow-up imaging hemodynamically
stable and no active bleeding
• •Zone III: Most common location of retroperitoneal
hemorrhage, associated with pelvic fracture
• •No exploration in blunt pelvic trauma
• •Surgery for penetrating trauma
42. Limbs
• Vascular injuries associated with fractures are
rare, occurring in only 0.5 to 3% of all patients
with extremity fractures.
• The importance of a careful neurologic
examination is important .
• Three different mechanisms can produce
paralysis and numbness in an injured
extremity: ischemia, nerve injury, and
compartment syndrome.
43. Prehospital
• As manual compression or the application of a
pressure dressing and
• Elevation of the extremity can almost always
control arterial bleeding from an extremity in
the field,
• Loss of life should be infrequent in an urban
setting.
45. Post op
• Postoperative monitoring of hand
perfusion and radial pulse is
recommended at least every 30 min
for the first 6 h. When deteriorated
function of the repaired artery is
suspected, duplex scanning can
verify or exclude postoperative
problems.
• Occausion ......reoperation
• Compartment syndrome
46. Complication
• Delayed diagnosis and treatment may lead
– Thrombosis
– Embolisation
– Rupture with hge.
• Risk factor for amputation
– Elevated compartment pressure
– Arterial transection
– Associate open fracture
– Combination above and below knee
48. In theatre
• Always establish good exposure
• Establish proximal then distal arterial control
• Use a shunt if the bones need to be fixed first to
buy you some time
• Use local heparin flush
• Make your arterial repair tension-free
• Use autogenous vein
• Repair concomitant venous injury if patient is
stable
51. Limbs
• Operative Principle
– Proximalldistal control
– Primary repair where possible
– Graft autogenous vein (contralateral limb)
– Temporary shunt
– Fixation of ortho-injury
– Coverage of repair (muscle, soft tissue)
– Fasciotomy
52. Extremities
•
•
•
•
•
Ligation may be acceptable in rare circumstances
If major Musculo-skeletal, neurological injury
Popliteal have the highest rate
Repair vein first
Compaerment syndrome
