Inaugural vascular symposium, trauma hard signs, treatment

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

2. Vascular trauma /injury
• Injury to
– Arteries
– Veins
• Anatomical regions
– Extremity – limbs
– Abdomen and pelvis
– Thorax
– Head and neck

3. Vascular trauma /injury
• Injury to
– Arteries
– Veins
• Anatomical regions
– Extremity – limbs
– Abdomen and pelvis
– Thorax
– Head and neck

4. CASE
• 23 Year old male
• Trap gun injury around knee joint
• Heavy bleeding at the time of injury
• Admitted to Teaching Hospital Anuradhapura
after 8 hours
• No Distal Pulses
• Pulse rate – 100 / min

5. CASE
• Reduced movements
• Numbness
• BP – 80 / 50 mm / Hg
• Clinical evidence of fracture around knee joint

6. CASE

7. Case
• Is there an arterial injury ?
• Why ?
• What are the signs and symptoms?

8. Mechanism of disruption of flow at arterial level
• Transection
• Laceration
• Contusion
• Kink
• Intimal flap

9. Vascular trauma
Signs of a vessel injury
• Hard signs
• Soft sign
Hard signs
– Active bleeding
– Signs of distal ischaemia
• Absent pulse
• Pain
• Pale
• Perishing Cold
• Paresthesia / anaesthesia
• Paresis / Paralysis
– Expanding hematoma
– Thrill, Bruits

10. Signs of a vessel injury
• Soft signs
– Hematoma
– Injury close to a known neurovascular bundle
– Reduced pulse

11. Case
• Is this late?
• Will you Repair?

12. Late Signs of a vessel injury
• Paresis / paralysis and paresthesia / anaesthesia
- late signs
• Paresis and paresthesia
• viability of the limb is in immediate threat
• Anaethesia and paralysis
• not viable.

13. Case
• What are the alternative explanations for the
above signs and symptoms

14. Problems with diagnosing ischaemia after
trauma
• Pain
– due to injury itself, may not have pain due to associated
nerve injury
• Pallor
– may be pale due to blood loss
• Absent pulse
– absent due to low blood pressure. Compare with othe
limb
• Paresthesia , paresis
– occur due to associated nerve, muscle injury or
unresponsive confused patient

15. CASE
• What do you do ?

16. CASE
• What do you do ?
– Resuscitate

17. CASE
• What do you do ?
– Resuscitate
– Explore immediately

18. CASE
• What do you do ?
– Resuscitate
– Explore immediately
– ? fasciotomy

19. CASE
• What do you do ?
– Resuscitate
– Explore immediately
– ? fasciotomy
– Investigate

20. CASE
• Two units of blood transfused
• BP – 110 / 70
• No distal pulse
• Now what
• Any investigations ?

21. X Ray

22. Investigation
• Hard signs
– Resuscitate and explore
• Soft sign
– Can investigate
• What other investigations are available?

23. Investigations
Investigations
•Hard signs
• urgent intervention
•Soft signs
• Observe
• Investigate

24. Investigations
• Hand held DOPPLER
• Absent doppler flow
• Quality of signal
• ABPI
• Presence of doppler flow does not exclude
vascular injury
• Duplex scan (USS + DOPPLER)
• Difficult to image in trauma
• Due to
• Pain, Non cooperative patient,
Dressings
• Patent distal vessels does not exclude a proximal
injury

25. Investigations
• Angiography
– CT angiography
– Catheter angiography

26. CT ANGIOGRAPHY

27. 3D Reconstruction

28. Conventional angiography / DSA
• Contrast directly into artery
• Traumatic
• DSA – Digital subtraction angiography
– done though a software after obtaining initial
images

29. Conventional angiography / DSA
• Contrast directly into artery
• Traumatic
• DSA – Digital subtraction angiography
– done though a software after obtaining initial
images

30. Investigations
• Arteriography
– On table / DSA –
for multi level injury

31. Investigations
• Patient presenting with
– Soft signs
– Delayed presentation
– Avf
– False aneurysm
– Pre-op angiography

32. Case
• In this patient – What investigations you
would request

33. X Ray

34. How soon we should we repair
– As soon as possible
– Effects of ischaemia

35. How soon we should we repair
• At ANP – 1 year
– 13 cases
– Commonest artery popliteal 53.8 %
– Mean ischaemic time – 12.67 hrs
– 4 clinically dead limb (mean time 15.75 hrs)

36. Case
• Will he need fasciotomy ?

37. WHAT ARE THE LEG COMPARTMENTS

38. LEG COMPARTMENTS

39. FASCIOTOMY

40. FASCIOTOMY

41. FASCIOTOMY

42. FASCIOTOMY

43. Fasciotomy
• 3 compartments dead
• Distal pulse absent
• Will you repair the artery ?

44. Surgical Repair
• Exploration done
• Contused artery
• What re the principles of repair

45. Surgical Repair
• Prompt transport to operating room
• General anesthesia
• Clean the entire limb
• Thigh prepared – for venous harvest
• Control of proximal and distal ends and trimming

46. Surgical repair (cont..)
• Balloon thrombectomy
• Systemic and distal heparinisation
• Interposition graft / Direct
approximation
– Unit experience – 88.2% RSVG
• Prosthesis
– lower patency
– infection

47. Surgical repair (cont..)

48. Principles of arterial repair
• Cut / laceration _ suture transversely
• Heparin – depends on clinical situation

49. Reperfused ..
• Tachycardia
• Transient lowering of blood pressure
• Recovered with fluid resuscitation
• Mannitol given
• At ICU alkaline diuresis

50. POST PERFUSION EFFECTS
• REPERFUSION INJURY
• REPERFUSION SYNDROME

51. • Local – reperfusion injury
– Paradoxycal death of already dying muscles after
reperfusion
• Systemic- Reperfusion syndrome
– Hypotension
– ARDS
– Lactic acidosis
– Hyperkalemia
– Renal failure
Reperfusion effects

52. • Fasciotomy
• Hydrate the patient
• Mannitol
• O2
• Inotropes
• Ligation of vessel if not responding to above
mesures
• Bicarbonate diuresis
Reperfusion syndrome- Management

53. • If urine out-put is adequate
– 5% Dextrose 800 ml + 8.4% NaHCO3 100 ml +20%
Manitol 100 ml
– 100 cc/hr for 12 hours
• If UOP is inadequate
– N/2 saline 500ml + 8.4% NaHCO3 35 ml
– Over 6 hours
– Do SE
Bi-carbonate diuresis/ forced alkaline
diuresis

54. What else can we do
• Compartment excision ?
• Ligation
• Amputation

55. Fracture
• What about bone

56. Combined Vascular and Skeletal
Trauma
– Revascularization / skeletal fixation (external
Fixator – EF)
• Bone fixation first if limb is not threatened – apply
EF antero laterally
• Revascularisation first if limb is threatened

57. Case
• Do you repair all injuries

58. Primary Amputation
• Extensive crush injuries and soft
tissue damage – “mangled limb”
• No need to transfer – discuss / photo

59. Case
• What will you do if threre are no facilities to
repair

60. In hospitals where facilities for
repair is not available
• ABCD
• Fasciotomy
• Discuss
• Transfer
• Do not apply tight dressings
• ? shunt

61. Summary
• Vascular injury;
– Resuscitate
– Assess viability and extent of injury
– Assess need for fasciotomy
– Early intervention and post intervention monitoring
– Rehabilitation

62. Thank You