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Emergencies in vascular surgery

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VASCULAR SURGICAL EMERGENCIES, REPERFUSION EFFECTS, COMPARTMENT SYNDROME, INTRA ARTERIAL INJECTION, FOR EMERGENCY MEDICINE TRAINEES

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Emergencies in vascular surgery

  1. 1. EMERGENCIES IN VASCULAR SURGERY Dr. JoelArudchelvam ConsultantVascular andTransplant Surgeon Teaching HospitalAnuradhapura
  2. 2. Some Vascular Emergencies  Acute limb Ischaemia  Accidental arterial injection  Compartment syndrome  Vascular trauma  Deep vein thrombosis
  3. 3. Acute limb Ischaemia  Sudden interruption of blood supply to limb resulting in threat to the limb viability.
  4. 4. Acute limb Ischaemia
  5. 5. Acute limb Ischaemia Presentation “ P ”s  Pain  pallor  Perishing cold  Pulselessness  Paresis / paralysis  Paraesthesia / anaesthesia. Beware  After trauma  After anaesthesia Diagnosis – Clinical  “do not waste time on investigation”
  6. 6. Acute limb Ischaemia Management  Recognize  Start unfractionated heparin  Loading dose 75 – 100 IU/Kg ( approximately 5000 IU )  Followed Infusion of heparin -18U/kg (approximately -1000U/hr)  Refer to vascular surgeon  Pain relief  Keep fasting  Check theViability of the limb - note.  Acute limb ischemia is a clinical diagnosis -there is no need of imaging.
  7. 7. Acute limb Ischaemia  Surgery  Embolectomy with fogarty catheter  Can be done under LA  Post op  Monitor distal pulse  Continue heparin  Start warfarin  Monitor for reperfusion effects
  8. 8. Reperfusion effects  Local  Reperfusion injury – paradoxical death of already dying muscles after reperfusion  Systemic  Reperfusion syndrome  Hypotension  ARDS  Lactic acidosis  Hyperkalemia  Renal failure
  9. 9. Reperfusion effects  Local  Reperfusion injury – paradoxical death of already dying muscles after reperfusion
  10. 10. DURING ISCHAEMIA
  11. 11. DURING ISCHAEMIA
  12. 12. AFTER REPERFUSION
  13. 13. AFTER REPERFUSION
  14. 14. MANAGEMENT OF REPERFUSION EFFECTS
  15. 15. MANAGEMENT OF REPERFUSION EFFECTS
  16. 16. Reperfusion effects  Systemic  Substances Released  Lactic Acid  K+  Inflammatory Mediators  Myoglobin  Activated Leucocytes  Etc.
  17. 17. Reperfusion effects  Systemic  Reperfusion syndrome  Hypotension  ARDS  Lactic acidosis  Hyperkalemia  Renal failure
  18. 18. Reperfusion effects  Mangement  Ligation of vessel if not responding to other supportive measures
  19. 19. Compartment syndrome Reduced organ perfusion due to increased intra compartment pressure.  Compartment Perfusion Pressure (CPP)  MeanArterial Pressure (MAP)  Intra Compartmental Pressure (ICP) CPP = MAP – ICP
  20. 20. Compartment syndrome Causes  Trauma (muscle contusion)  Haematoma  Reperfusion  Intracompartmental extravasation of fluids  Tight bandage, cast
  21. 21. Compartment syndrome Clinical features  Excessive pain - pain on passive movements  Numbness -e.g. anterior compartment first toe web (deep peroneal nerve )  Tense swollen leg  Do not look for absent distal pulse – late
  22. 22. Compartment syndrome Treatment  Recognize  Remove the cause  Reduce intracomparmental pressure  Remove bandages and cast  Fasciotomy
  23. 23. Compartment syndrome Treatment
  24. 24. Compartment Syndrome Fasciotomy
  25. 25. Accidental intra-arterial injection  Problems  Haematoma / false aneurysm  Ischaemia  Due to arterial dissection and thrombosis  Due to the effects of the drugs
  26. 26. Accidental intra-arterial injection Drugs causing ischaemia / necrosis Hyperosmolar Acids/alkalis Vasoconstrictors Calcium chloride Aminophylline Epinephrine Calcium gluconate Amiodarone Dobutamine Magnesium sulphate Amphotericin Dopamine Parenteral nutrition Diazepam Metaraminol Potassium chloride Phenytoin Norepinephrine Sodium bicarbonate Thiopental Vasopressin Vancomycin
  27. 27. Pathophysiology  Arterial Spasm  Chemical Arteritis  Crystal Formation
  28. 28. Accidental intra-arterial injection Recognition  Flashback -pulsatile.  Flashback blood redder than usual.  Haematoma formation  severe discomfort distal to the site of injection  Signs of distal ischemia  Pain  Pale /cyanosis  Perishing Cold  Absent pulse  Paresthesia / anaesthesia  Paresis / Paralysis
  29. 29. Accidental intra-arterial injection Management  Stop the injection  Leave the cannula in place  Vascular surgical referral  Anticoagulation – heparin 75U/ Kg stat and 18 U/ Kg hourly  Inject lidocaine, papaverine through cannula
  30. 30. Accidental intra-arterial injection Management cont…  Calcium channel blockers  Aspirin, Methylprednisolone –Thromboxane blocker  Iloprost - Prostacycline analogue  Stellate ganglion block - vasodilatation  Analgesia
  31. 31. Vascular trauma / injuries Causes  RoadTraffic injuries – 60%  Trap Gun  Iatrogenic - 25%  Penetrating / Sharp  Blunt
  32. 32. Mechanism of disruption of flow at arterial level  Transection  Laceration  Contusion  Kink  Intimal flap
  33. 33. Vascular trauma Signs of a vessel injury  Hard signs  Active bleeding  Thrills, Bruits  Signs of distal ischemia  Absent pulse  Pain  Pale  Perishing Cold  Paresthesia / anaesthesia  Paresis / Paralysis  Expanding hematoma
  34. 34. Vascular trauma  Soft signs  Reduced pulse  Hematoma  Injury close to a known neurovascular bundle  paresis/ paralysis and paresthesia / anaesthesia - late signs  Paresis and paresthesia - viability in immediate threat  Anaethesia and paralysis -not viable.
  35. 35. Investigations Investigations • Hard signs • urgent intervention • Soft signs • Observe • Investigate
  36. 36. Investigations • Hand held Doppler • Absent Doppler flow • Quality of signal • Duplex scan (USS + Doppler ) • Difficult to image in trauma • Due to • Pain • Non cooperative patient • Dressings
  37. 37. Investigations  Angiography  CT angiography  Catheter angiography
  38. 38. CT ANGIOGRAPHY
  39. 39. TREATMENT Surgical Repair  Prompt transport to operating room  Entire limb cleaned should be able to palpate distal pulses.  Thigh prepared – for venous harvest  Mobilisation and control of proximal and distal arterial ends and trimming
  40. 40. Surgical repair (cont..)  Balloon thrombectomy  Systemic and distal heparinisation  Interposition graft / Direct approximation  Unit experience – 88.2% RSVG  Prosthesis  lower patency  infection
  41. 41. Surgical repair (cont..)
  42. 42. POST OPERATIVE MONITORING  Monitor distal pulse / Sao2  Keep limb elevated  Check movement and sensation  Follow surgical instruction regarding anticoagulation  Look for compartment syndrome  Look for post perfusion effects  Do not apply encircling dressings
  43. 43. Deep Vein Thrombosis  Thrombosis – formation of solid material within the circulation using blood components.  Phlebothrombosis  Thrombophlebitis
  44. 44. DVT Causes - Virchows triad
  45. 45. Clinical presentation  Leg swelling  Pain
  46. 46. Investigations  D dimer  Originate from clot lysis  Duplex scan ( USS + Doppler)  Solid material inside vessel  Non compressible  Absent flow
  47. 47. Diagnosis and treatment
  48. 48. Diagnosis and treatment  LMWH (low molecular weight heparin) – e.g. Enoxaparin (1 mg/kg twice daily SC), dalteparin, tinzaparin  Advantages  does not require infusion  Does not need frequent monitoring  Unfractionated Heparin o Loading dose 75 – 100 IU/Kg ( approx 5000 IU ) o Followed by Infusion of heparin -18U/kg (approx - 1000U/hr ) o monitored with APTT. (Keep APTT between 60 to 80s)
  49. 49. Diagnosis and treatment  Also Start o Warfarin o10 mg D1 o10 mg D2 o5 mg D3  Target INR - between 2 – 3  When INR between 2 - 3 for 2 days omit heparin.  Continue warfarin for 3 months
  50. 50. Diagnosis and treatment  Other measures  Analgesics  Compression stocking  Foot end elevation  Hydration  Young recurrent DVT – haematology referral
  51. 51. Pulmonary embolism  PE occurs in 60 to 80% of patients with DVT  Only half are symptomatic  4% massive PE, Mortality – 60%
  52. 52. Pulmonary embolism  Clinical features depends on the size of the embolus  Small – lodges at peripheral pulm.Vessels  Pain (pleuritic), effusion  Larger – at branching points  Wedge shaped infarction  Pleuritic pain,effusion, tachypnoea  Massive – occludes the bifurcation  Sudden onset pain  SOB  Haemodynamic instability
  53. 53. Pulmonary embolism  Diagnosis  Gold standard – CT pulmonary angiogram
  54. 54. Pulmonary embolism  Other tests  Arterial Blood Gases  Hypoxemia  Hypocapnia  Alkalosis  ECG – only 20% has classic changes  S1 Q3 T3  Right heart strain  Tall P waves in lead II (P pulmonale), R axis deviation, RBBB  2D ECHO – R heart strain
  55. 55. Vascular emergencies  Look for / monitor  Recognize  Refer
  56. 56. Thank You

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