peripheral vascular injury, mechanisms, complications and management by Joel Arudchelvam

1. Joel Arudchelvam

2. 1.Sharp
 knife
 shrapnel
2. Blunt
 joint dislocation
 fracture

3. 1.Transection / cut
2. Laceration
3.contusion
4.dissection

4. 1.Bleeding / haematoma
2.Ischaemia
3.Complications of vascular injury (Refer later)

5. Bleeding
a. In extremities - obvious, may have stopped at
the time of admission therefore a history of
bleeding is important,haematoma (especially
expanding)
b. In abdominal and thoracic arterial injury -
hypotension

6. In extremities P's
1. Pain
2. Pallor
3. Pulsenessness
4. Perishing cold
5. Paresthesia/anesthesia
6. Paresis/paralysis
In other areas signs and symptoms of relevant organ
ischaemia. e.g. cerebral, renal. Ect.

7. 1. Hard
A. Active bleeding
B. expanding haematoma
C. Distal ischemia ( P's)
D. Bruit, thrill
2. Soft
A. Haematoma
B. injury close to known neurovascular bundle
C. History of bleeding

8. 1.pain
could be due to injury itself, may not have pain due to associated
nerve injury
2.pallor
may be pale due to blood loss
3. Absent pulse
may be absent due to low blood pressure. Compare with othe limb.
4.paresthesia , paresis
may occur due to associated nerve, muscle injury or unresponsive
confused patient

9. limbs with paresthesia and paresis are in immediate
threat and should be explored and repaired at
theatre as soon as possible.
1.Doppler
Absent doppler signal indicates no flow, presence of doppler
signal indicate there is flow in the vessel examined.
Character of doppler may give a clue to the quality of flow
i.e. Triphasic however this willnot exclude an injury. Also
help to measure ABPI in both limbs for comparison

10. Duplex scan - difficult to perform in the setting of
trauma due to incorporative patient, presence of
wound and dressings and pain.
CT ANGIOGRAPHY - Helps to locate, to assess the
extent of injury, to identify associated injuries and to
plan the treatment.
On table angiography - in cases needing urgent
exploration and having multilevel injuries. i.e trap
gun injury

11. ABCD
Urgent exploration
Repair - Direct, interposition graft
Ligation – non important arteries and as a damage
control procedure

12. Urgent transfer after stabilisingABCD
FASCIOTOMY

13.  Ischemia reperfusion injury
 Compartment syndrome
 Arteriovenous fistula
 False aneurysm
 Death

14.  During ischaemia
 Anaerobic metabolism – lactic acidosis
 Reduced ATP – reduced activity of ion pump – accumulation of
intracellular Ca2+, Na+ and other ions, increased permeability
 Ca2+ - activation of phospholipases and proteases
 Activation of Xanthine oxidase
 Increased membrane adhesiveness and Stasis leading to
prothrombotic effects

15.  During reperfusion
 Local
 Influx of O2 and cells
 resulting in production of oxygen radicals
 Adhesion of cells leading to congestion and oedema
 Systemic
 Acidosis
 Acute kidney injury
 ARDS
 Hyperkalemia
 Hypotension
 DIC

16.  Revascularization as early as possible
 Fasciotomy and excision of dead muscle
 Heparinisation
 Hydration
 Oxygen
 Mannitol, allopurinol

17. Reduced organ / tissue perfusion as a result of
increased intracompartmental pressure
Happen in tight compartments
Results in vicious cycle of ischemia and swelling
and eventual muscle death

19.  Early revascularisation
 Elevation
 Fasciotomy

21. Thank You