This document discusses vascular injuries to the extremities in Sri Lanka. It notes that the main causes are road traffic accidents (38.5%) and trap guns (7.5%). Successful management requires early detection and intervention, but there are challenges with delayed detection, transport times, limited trained staff and infrastructure. The author operated on 4 limbs that were considered marginally viable or dead after revascularization, with some improvement in sensation but limited motor recovery. Overall it emphasizes the need for dedicated trauma centers, adequate trained staff and prompt transport to improve outcomes for extremity vascular injuries in Sri Lanka.

1. Joel Arudchelvam
ConsultantVascular andTransplant Surgeon

2. TEACHING HOSPITAL ANURADHAPURA

3. TEACHING HOSPITAL ANURADHAPURA

4. VASCULAR INJURY
 Head And Neck
 Thorax
 Abdomen and Pelvis
 Limbs (Extremity )

5. VASCULAR INJURY
 Head And Neck
 Thorax
 Abdomen and Pelvis
 Limbs (Extremity )

6. VASCULAR INJURY
 Head And Neck
 Thorax
 Abdomen and Pelvis
 Limbs (Extremity )

7. VASCULAR INJURY
 Head And Neck
 Thorax
 Abdomen and Pelvis
 Limbs (Extremity )

8. EXTREMITY VASCULAR INJURIES
 Common
 Results in limb loss at times loss of life
 Loss of earning capacity
 Economic burden

9. CAUSES
 RoadTraffic Accidents – 38.5%
 Trap gun – 7.5%
 Fractures and dislocations
 Cuts and stabs
 Iatrogenic
Teaching Hospital Anuradhapura 2015

10. TRAP GUN
 Made of a metal pipe,
metal pallets and
explosives (from fire
cracker)
 About 75 trap gun injury /
year
 About 10 – 15 % with
arterial injuries
 Multilevel injury
Teaching Hospital Anuradhapura 2015

11. CAUSES
 RoadTraffic Accidents – 38.5%
 Trap gun – 7.5%
 Fractures and dislocations
 Cuts and stabs
 Iatrogenic – 5 cases
Teaching Hospital Anuradhapura 2015

12. CAUSES
 RoadTraffic Accidents – 38.5%
 Trap gun – 7.5%
 Fractures and dislocations
 Cuts and stabs
 Iatrogenic – 5 cases
 Accidental cannulation of femoral artery in
infants and iliac vessel injury following
discectomy
Teaching Hospital Anuradhapura 2015

13. CAUSES
 RoadTraffic accidents – 38.5%
 Trap gun – 7.5%
 Fractures and dislocations
 Cuts and stabs
 Iatrogenic
 Mechanism of injury
 Sharp / penetrating
 Blunt

14. MECHANISM OF DISRUPTION ARTERIAL
LEVEL
 Transection
 Laceration
 Contusion
 Kink
 Intimal flap

15. VASCULAR TRAUMA
Signs of a vessel injury
 Hard signs
 Soft sign

16. VASCULAR TRAUMA
Hard signs
 Active bleeding
 Signs of distal ischaemia – ‘ Ps ’
 Absent pulse
 Pain
 Pale
 Perishing Cold
 Paresthesia / Anaesthesia
 Paresis / Paralysis
 Thrills, Bruits
 Expanding hematoma

17. VASCULAR TRAUMA
 Soft signs
 Hematoma
 Injury close to a known neurovascular
bundle
 Reduced pulse

18. VASCULAR TRAUMA
 Soft signs
 Hematoma
 Injury close to a known neurovascular
bundle
 Reduced pulse
 Hard signs – explore
 Soft signs – observe

19. VASCULAR TRAUMA
 Paresis / Paralysis & Paresthesia / Anaesthesia
 Late Signs
 Paresis & Paresthesia
 Viability OfThe Limb Is In ImmediateThreat
 Anaethesia & Paralysis
 NotViable

20. PROBLEM WITH VASCULAR INJURY
Delay α Dead Limb

21. SUCCESSFUL MANAGEMENT OF EXTREMITY
VASCULAR INJURY
 Early Detection
 Early intervention

22. CHALLENGES
 Failure to detect early
 Transport and Communication
 Trained Staff, ability to handle Case load and
Infrastructure

23. SUCCESSFUL MANAGEMENT OF EXTREMITY
VASCULAR INJURY
 Delay in Detection
 Delayed intervention

24. FAILURE TO DETECT EARLY
 Lack of knowledge
 Busy emergency units

25. TRANSPORT
 Ambulance service
 Traffic
 All takes time

26. TRANSPORT
 When patient reaches
 Not fit for intervention
 Limb is not viable
 Mean ischaemic time - 12.6 hours (0.5 to 48)
 Clinically marginally viable / nonviable limbs -
15.75 (7.5 to 25.5) hours

27. TRANSPORT
 Staff transport
 Most live away fromAnuradhapura
 Average distance to travel – 85km
 Mode – own vehicle and self driving
 No official transport

28. TRANSPORTATION
Average time from
injury to reperfusion
- 12.6 hours (0.5 to 48)

29. CASE LOAD, TRAINED STAFF AND
INFRASTRUCTURE

30. CASE LOAD
Anuradhapura
district
Population –
860,575 (4.2%)

31. CASE LOAD
Other areas
covered
Total population
covered -
5,546,355 (27%)

32. CASE LOAD, TRAINED STAFF AND
INFRASTRUCTURE
 No dedicated trauma centers and theatres
 9 vascular surgeons
 Only 1 – in north and north central region – 27%
of population
 Number of other doctors
 Number of nurses and associated staff

33.  Insert ministry charts

34.  Insert ministry charts

37. STAFF
Medical officers - 05
Nurses - 15
• Ward
• Theatre
• HDU

38. “DEAD LIMBS”
 Dead or marginally viable limb - anesthetic and
paralytic or after fasciotomy if two or more
compartments are non-viable
 Revascularization done if:
 Young
 Systemically well
 No severe soft tissue injury
 Local infection
Arudchelvam, J., (2017). Outcome after revascularisation of marginally viable limbs and dead limbs following lower
limb arterial injuries. Ceylon Medical Journal. 62(3), pp.203–204. DOI: http://doi.org/10.4038/cmj.v62i3.8526

39. RESULTS
 Dead or marginally viable limb revascularized -
4/13
 Mean ischaemic time was 15.75 (7.5 to 25.5)
 All underwent fasciotomy to confirm viability
 reduced sensation before revascularisation
improved following revascularization in all
 Only 25% improvement in motor function
Arudchelvam, J., (2017). Outcome after revascularisation of marginally viable limbs and dead limbs following lower
limb arterial injuries. Ceylon Medical Journal. 62(3), pp.203–204. DOI: http://doi.org/10.4038/cmj.v62i3.8526

40. HOW CAN WE IMPROVE…..
 Needs to have;
 DedicatedTrauma centers
 AdequateTrained staff
 Prompt transport facilities
 We need to increase the threshold for
revascularizing dead limbs
Arudchelvam, J., (2017). Outcome after revascularisation of marginally viable limbs and dead limbs following lower
limb arterial injuries. Ceylon Medical Journal. 62(3), pp.203–204. DOI: http://doi.org/10.4038/cmj.v62i3.8526

41. ThankYou