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Vasular trauma
The document discusses vascular trauma, which includes injuries to arteries and veins in various anatomical regions such as extremities, abdomen, and thorax. It outlines causes, mechanisms of injury, signs of vascular injury, and the importance of timely diagnosis and surgical repair. The document emphasizes the management of vascular injuries, potential complications, and the need for urgent intervention to restore blood flow and limb viability.
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Vasular trauma
- 1. Vascular Trauma Joel Arudchelvam ConsultantVascular 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. Extremity Vascular Injuries •Unexpected • Young and fit • Results in limb loss at times loss of life • Loss of earning capacity • Economic burden
- 5. Causes • Road TrafficAccidents – 38.5% • Trap Gun – 7.5% • Home Accidents - 7.5% • Cuts and Stabs • Iatrogenic - 46.1% Mechanism of injury • Sharp / penetrating • Blunt
- 6. Mechanism of disruptionof flow at arterial level • Transection • Laceration • Contusion • Kink • Intimal flap
- 7. Vascular trauma Signs ofa vessel injury • Hard signs • Soft sign Hard signs – Active bleeding – Thrills, Bruits – Signs of distal ischaemia • Absent pulse • Pain • Pale • Perishing Cold • Paresthesia / anaesthesia • Paresis / Paralysis – Expanding hematoma
- 8. Signs of avessel injury • Soft signs – Hematoma – Injury close to a known neurovascular bundle – Reduced pulse • Paresis / paralysis and paresthesia / anaesthesia - late signs • Paresis and paresthesia – viability of the limb is in immediate threat • Anaethesia and paralysis – not viable.
- 9. Problems with diagnosingischaemia after trauma • Pain – Due to injury itself • Pallor – Pallor due to blood loss • Absent pulse – Absent due to low blood pressure. Compare with othe limb • Paresthesia , paresis – Due to associated nerve, muscle injury or unresponsive patient
- 10. Investigations Investigations • Hard signs •Urgent intervention • Soft signs • Observe • Investigate
- 11. Investigations • Hand heldDOPPLER • Absent doppler flow • Quality of signal • ABPI • Presence of doppler flow does not exclude vascu lar injury • Duplex scan (USS + DOPPLER) • Difficult to image in trauma • Due to • Pain, Non cooperative patient, Dressi ngs • Patent distal vessels does not exclude a proximal injury
- 12. Investigations • Angiography – CTangiography – Catheter angiography
- 13. CT ANGIOGRAPHY • Anatomy •Site of Injury • Soft tissue and bone • 3D reconstruction
- 14. Conventional angiography /DSA • Contrast directly into artery • Traumatic • DSA – Digital subtraction angiography – done though a software after obtaining initial images
- 15. Conventional angiography /DSA • Contrast directly into artery • Traumatic • DSA – Digital subtraction angiography – done though a software after obtaining initial images
- 16. Investigations • Arteriography – Ontable / DSA – for multi level injury
- 17. Investigations • Patient presentingwith – Soft signs – Delayed presentation – Avf – False aneurysm – Pre-op angiography
- 18. How soon weshould we repair – As soon as possible – Effects of ischaemia
- 19. How soon weshould 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)
- 20. Surgical Repair • Prompttransport to operating room • General anesthesia • Clean the entire limb • Thigh prepared – for venous harvest • Control of proximal and distal ends and trimming
- 21. Surgical repair (cont..) •Balloon thrombectomy • Systemic and distal heparinisation • Interposition graft / Direct approxi mation – Unit experience – 88.2% RSVG • Prosthesis – lower patency – infection
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- 23. Principles of arterialrepair • Cut / laceration _ suture transversely • Heparin – depends on clinical situation
- 24. Combined Vascular andSkeletal Trauma – Revascularization / skeletal fixation (external Fixat or – EF) • Bone fixation first if limb is not threatened – apply EF ante ro laterally • Revascularisation first if limb is threatened
- 25. Primary Amputation • Extensivecrush injuries and soft tissue damage – “mangled limb” • No need to transfer – discuss / photo
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- 27. Reperfusion effects • Reperfusioninjury – paradoxical death of already dying cells when reperfused • Post perfusion syndrome – systemic effects of reperfusion
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- 29. Compartment syndrome Reduced organperfusion due to increased intra compartment pressure. Recognize Remove the cause Surgery – fasciotomy
- 30. Compartment Syndrome Treatment –Fasciotomy
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- 36. Post perfusion syndrome •ACIDOSIS • ARDS • AKI • MYOCARDIA DEPRESSION • DIC • MYOGLOBINURIA • HYPERKALEMIA • ETC.
- 37. Post perfusion syndrome •How to minimise – hydration and maintain UOP – keep on O2 – Mannitol – Correct acidosis / hyperkalemia – Inotropes
- 38. In hospitals wherefacilities for repair is not available • ABCD • Fasciotomy • Discuss • Transfer • Do not apply tight dressings
- 39. Summary • Vascular injury; –Resuscitate – Assess viability and extent of injury – Assess need for fasciotomy – Early intervention and post intervention monitoring – Rehabilitation
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