vascular injury at peripheral hospital settings, causes, hard and soft signs,challenges

1. Joel Arudchelvam
Consultant Vascular and Transplant Surgeon
Teaching Hospital Anuradhapura

5. Population –
860,575 (4.2%)
2012 census

6. Total population
covered -
5,546,355 (27%)
No of vascular
Surgeons – 1

7.  Results in limb loss at times loss of life
 Loss of earning capacity
 Economic burden

8.  Road Traffic Accidents – 38.5%
 Trap Gun – 7.5%
 Home Accidents - 7.5%
 Cuts and Stabs
 Iatrogenic

9.  Made of a metal pipe,
metal pallets and
explosives (from fire
cracker)
 About 75 trap gun injury
victims per year
 About 10 – 15 % with
arterial injuries
 Multilevel injury

10.  Road Traffic accidents – 38.5%
 Trap gun – 7.5%
 Home accidents - 7.5%
 Cuts and stabs
 Iatrogenic – 46.1%

11.  Road Traffic Accidents – 38.5%
 Trap Gun – 7.5%
 Home Accidents - 7.5%
 Cuts and Stabs
 Iatrogenic – 46.1%
 accidental cannulation of femoral artery in infants
 Mechanism of injury
 Sharp / Penetrating
 Blunt

12.  Transection
 Laceration
 Contusion
 Kink
 Intimal Flap

13. Signs of a Vessel Injury
 Hard Signs
 Soft Sign
Hard signs
 Active bleeding
 Thrills, Bruits
 Signs of distal Ischaemia
 Absent pulse
 Pain
 Pallor
 Perishing Cold
 Paresthesia / Anaesthesia
 Paresis / Paralysis
 Expanding hematoma

14.  Soft Signs
 Hematoma
 Injury close to a known neurovascular bundle
 Reduced pulse

15.  Paresis / Paralysis and Paresthesia / Anaesthesia
 late signs
 Paresis and Paresthesia
 Viability of the limb is in immediate threat
 Anaethesia and paralysis
 Not viable.

16.  Transport
 Training, Infrastructure, Work force
 Communication

17.  Common modes – Three wheelers, Motorbikes
 No ambulance service
 Traffic
 Transfer to a vascular center
 Detecting a vascular injury
 Ambulance
 All takes time

18.  When patient reaches
 Limb is not viable
 Not fit for intervention
 Vascular injury
 Duration of ischaemia ∞ non viability of limb
 Mean ischaemic time - 12.6 hours
 Clinically marginally viable / nonviable limbs -
15.75 (7.5 to 25.5) hours

19.  No dedicated trauma centers and theatres
 9 vascular surgeons
 1 – in North and North Central region –
27% of population
 Number of other doctors
 Number of nurses and associated staff
 Staff not familiar with procedures and
instruments

21.  No dedicated trauma centers and theatres
 9 vascular surgeons
 1 – in north and north central region – 27%
of population
 Number of other doctors
 Number of nurses and associated staff
 Staff not familiar with procedures and
instruments

23.  No dedicated trauma centers and theatres
 9 vascular surgeons
 1 – in north and north central region – 27%
of population
 Number of other doctors
 Number of nurses and associated staff
 Staff not familiar with procedures and
instruments

24.  Not all patients with vascular injury needed to be
transferred
 No need of intervention
 Not fit for intervention
 To administer pre transfer management
 Fasciotomy
 To view imaging
 Electronic transferring

25.  Dead or marginally viable limb - anesthetic and
paralytic / two or more compartments are non-viable
 Revascularization done if:
 Young – (less than 50 years)
 Systemically well
 No severe soft tissue injury
 Local infection
 All underwent fasciotomy to confirm viability

26.  Dead or marginally viable limb revascularized - 4/14
 Mean ischaemic time was 15.75 (7.5 to 25.5)
 Sensation improved following revascularization in all
 Only 25% had improvement in motor function

27.  Vascular Trauma in peripheries
 Need to establish
 Better transport service
 Trauma centers with dedicated vascular theatres
 Training of staff (more vascular surgeons, training of other
staff)
 We need to increase the threshold for revascularizing
dead limbs

29. Thank You