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Vascular Emergencies

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an introductory discussion of vascular emergencies for the first responder

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Vascular Emergencies

  1. 1. VASCULARVASCULAR EMERGENCIESEMERGENCIES STEVE HENAO MDSTEVE HENAO MD Vascular Surgery & Vascular InterventionalVascular Surgery & Vascular Interventional RadiologyRadiology New Mexico Heart InstituteNew Mexico Heart Institute
  2. 2. STEVE HENAO MDSTEVE HENAO MD ACUTE LIMB ISCHEMIAACUTE LIMB ISCHEMIA SUDDENSUDDEN DETERIORATION OF THE ARTERIALDETERIORATION OF THE ARTERIAL SUPPLYSUPPLY CAUSESCAUSES TRAUMATRAUMA IATROGENICIATROGENIC EMBOLISMEMBOLISM THROMBOSISTHROMBOSIS
  3. 3. STEVE HENAO MDSTEVE HENAO MD EMBOLISMEMBOLISM from the Greekfrom the Greek embolosembolos,, or “plug”or “plug” usually occurs in otherwise normal arteriesusually occurs in otherwise normal arteries
  4. 4. STEVE HENAO MDSTEVE HENAO MD ThrombosisThrombosis ““blood clotting within an artery”blood clotting within an artery” progressiveprogressive atherosclerotic obstructionatherosclerotic obstruction hypercoagulabilityhypercoagulability aortic or arterial dissectionaortic or arterial dissection
  5. 5. STEVE HENAO MDSTEVE HENAO MD Clinical PresentationClinical Presentation acute ischemia affectsacute ischemia affects sensorysensory nerves firstnerves first motormotor nervesnerves skinskin muscle tissuemuscle tissue muscle tenderness is one of the end-stagemuscle tenderness is one of the end-stage signssigns
  6. 6. STEVE HENAO MDSTEVE HENAO MD historyhistory DURATION OF SYMPTOMSDURATION OF SYMPTOMS IS THE MOSTIS THE MOST IMPORTANT PART OF THE HXIMPORTANT PART OF THE HX irreversible muscle necrosis inirreversible muscle necrosis in 6 - 8 hours6 - 8 hours
  7. 7. STEVE HENAO MDSTEVE HENAO MD physicalphysical ““P’sP’s”” pain, pallor, paresis, pulse deficit, paresthesia,pain, pallor, paresis, pulse deficit, paresthesia, poikilothermypoikilothermy
  8. 8. STEVE HENAO MDSTEVE HENAO MD Initial managementInitial management immediate anticoagulation withimmediate anticoagulation with heparinheparin leg stabilizationleg stabilization prevent deteriorationprevent deterioration O2O2 by facemaskby facemask improve skin perfusionimprove skin perfusion IVFIVF resucitationresucitation catheter monitoring for urine outputcatheter monitoring for urine output analgesiaanalgesia
  9. 9. STEVE HENAO MDSTEVE HENAO MD VASCULAR TRAUMAVASCULAR TRAUMA - head and neck- head and neck - head and neck- head and neck Penetrating injuriesPenetrating injuries 80% of deaths are80% of deaths are strokestroke relatedrelated
  10. 10. STEVE HENAO MDSTEVE HENAO MD Clinical presentationClinical presentation Neck classically divided intoNeck classically divided into “zones”“zones” IIIIII: above the angle of the: above the angle of the mandiblemandible IIII: between cricoid and: between cricoid and mandiblemandible most common (47%)most common (47%) II: below cricoid: below cricoid
  11. 11. STEVE HENAO MDSTEVE HENAO MD evaluationevaluation Hard signsHard signs:: 97% have a vascular injury97% have a vascular injury shock, refractory hypotension, pulsatileshock, refractory hypotension, pulsatile bleeding, bruit, enlarging hematoma, lossbleeding, bruit, enlarging hematoma, loss of pulse with stable or evolving neurologicof pulse with stable or evolving neurologic deficitdeficit Soft signs:Soft signs: only 3% have a vascular injuryonly 3% have a vascular injury hx of bleeding at scene, stablehx of bleeding at scene, stable hematoma, nerve injury, proximity of thehematoma, nerve injury, proximity of the injury track, unequal arm BPsinjury track, unequal arm BPs
  12. 12. STEVE HENAO MDSTEVE HENAO MD
  13. 13. STEVE HENAO MDSTEVE HENAO MD BCVIBCVI ““blunt cerebrovascular injury”blunt cerebrovascular injury” less than 1% of all admissions for blunt traumaless than 1% of all admissions for blunt trauma stroke rates range from 25 to 58%stroke rates range from 25 to 58% mortality rates 31 to 59%mortality rates 31 to 59% many patients initially asymptomaticmany patients initially asymptomatic can develop symptoms from 1 hr to many weekscan develop symptoms from 1 hr to many weeks screeningscreening
  14. 14. STEVE HENAO MDSTEVE HENAO MD BCVIBCVI
  15. 15. STEVE HENAO MDSTEVE HENAO MD BCVIBCVI • 16 slice16 slice CTACTA has been validated as the primaryhas been validated as the primary screening modality for BCVIscreening modality for BCVI
  16. 16. STEVE HENAO MDSTEVE HENAO MD BCVIBCVI • The mainstay of treatment for BCVI isThe mainstay of treatment for BCVI is antithrombotic therapyantithrombotic therapy • If the patient has no contraindications toIf the patient has no contraindications to anticoagulation, a prudent protocol would beanticoagulation, a prudent protocol would be heparin therapy (goal, activated partialheparin therapy (goal, activated partial thromboplastin time of 50 to 60 seconds) andthromboplastin time of 50 to 60 seconds) and transition to warfarin (goal, internationaltransition to warfarin (goal, international normalized ratio of 2.0) for 3 months.normalized ratio of 2.0) for 3 months. • Antiplatelet therapy should be used for theAntiplatelet therapy should be used for the same period.same period.
  17. 17. STEVE HENAO MDSTEVE HENAO MD Subclavian InjurySubclavian Injury • Injuries to the thoracic outlet are often lethal.Injuries to the thoracic outlet are often lethal. Prehospital mortality is 50% to 80%, and ofPrehospital mortality is 50% to 80%, and of those patients who survive transport, 15% diethose patients who survive transport, 15% die during treatment.during treatment. • long-term morbidity may be secondary tolong-term morbidity may be secondary to brachial plexus injuries.brachial plexus injuries. • Endovascular treatmentEndovascular treatment in this area can obviatein this area can obviate the need for extensive dissection at the base ofthe need for extensive dissection at the base of the neck.the neck.
  18. 18. STEVE HENAO MDSTEVE HENAO MD
  19. 19. STEVE HENAO MDSTEVE HENAO MD Cervical Venous InjuriesCervical Venous Injuries • If the patient has hard signs of a vascular injuryIf the patient has hard signs of a vascular injury and is in extremis,and is in extremis, the neck and subclavianthe neck and subclavian veins can be ligated with limited morbidityveins can be ligated with limited morbidity.. • If the internal jugular vein is ligated, the patientIf the internal jugular vein is ligated, the patient should be monitored forshould be monitored for cerebral edemacerebral edema;; however, this is a rare occurrence, even withhowever, this is a rare occurrence, even with bilateral internal jugular vein ligation.bilateral internal jugular vein ligation.
  20. 20. STEVE HENAO MDSTEVE HENAO MD VASCULAR TRAUMA:VASCULAR TRAUMA: thoracicthoracic thoracicthoracic BLUNT AORTIC INJURYBLUNT AORTIC INJURY 80% caused by MVC80% caused by MVC head-on collisions - most commonhead-on collisions - most common pts young - mean age: 39pts young - mean age: 39 9% survival at scene/9% survival at scene/ 98% overall mortality98% overall mortality substance abuse is a factor in 40%substance abuse is a factor in 40% seat belt use decreases risk by a factor of 4seat belt use decreases risk by a factor of 4 ejection from vehicle doubles the riskejection from vehicle doubles the risk
  21. 21. STEVE HENAO MDSTEVE HENAO MD BAIBAI CXRCXR subxiphoid ultrasoundsubxiphoid ultrasound multi - slice CTAmulti - slice CTA ONCE DIAGNOSIS IS MADE = IMMEDIATEONCE DIAGNOSIS IS MADE = IMMEDIATE SURGERYSURGERY
  22. 22. STEVE HENAO MDSTEVE HENAO MD VASCULAR TRAUMA:VASCULAR TRAUMA: abdominalabdominal abdominalabdominal penetrating trauma responsible for 90% ofpenetrating trauma responsible for 90% of abdominal vascular injuriesabdominal vascular injuries LOW VELOCITY: DIRECT INJURY TO VESSELLOW VELOCITY: DIRECT INJURY TO VESSEL HIGH VELOCITY: SHOCK WAVE/TRANSIENTHIGH VELOCITY: SHOCK WAVE/TRANSIENT CAVITATIONCAVITATION
  23. 23. STEVE HENAO MDSTEVE HENAO MD blunt abdominal traumablunt abdominal trauma rapid deceleration (MVC, falls)rapid deceleration (MVC, falls) direct AP crushing (seat belt, direct blows)direct AP crushing (seat belt, direct blows) direct laceration by bone fragment (severedirect laceration by bone fragment (severe pelvic fx)pelvic fx)
  24. 24. STEVE HENAO MDSTEVE HENAO MD
  25. 25. STEVE HENAO MDSTEVE HENAO MD common vessels injuredcommon vessels injured IVC : 25%IVC : 25% Aorta : 21%Aorta : 21% Iliac arteries : 20%Iliac arteries : 20% Iliac veins : 17%Iliac veins : 17% superior mesenteric vein :11%superior mesenteric vein :11% superior mesenteric artery : 10%superior mesenteric artery : 10%
  26. 26. STEVE HENAO MDSTEVE HENAO MD Prehospital treatmentPrehospital treatment Rapid transportation to Trauma CenterRapid transportation to Trauma Center ““SCOOP AND RUN”SCOOP AND RUN” ‘‘CONTROLLED HYPOTENSIONCONTROLLED HYPOTENSION’’ trying to balance exanguination againsttrying to balance exanguination against cardiac arrestcardiac arrest Immediate surgical control of the bleedingImmediate surgical control of the bleeding
  27. 27. STEVE HENAO MDSTEVE HENAO MD • Computed tomography (CT) has little or no roleComputed tomography (CT) has little or no role in suspected vascular injuries resulting fromin suspected vascular injuries resulting from penetrating traumapenetrating trauma during the acute stage.during the acute stage. However, it may play a useful role in bluntHowever, it may play a useful role in blunt trauma by identifying large hematomas, falsetrauma by identifying large hematomas, false aneurysms, or vessel occlusionsaneurysms, or vessel occlusions
  28. 28. STEVE HENAO MDSTEVE HENAO MD
  29. 29. STEVE HENAO MDSTEVE HENAO MD
  30. 30. STEVE HENAO MDSTEVE HENAO MD
  31. 31. STEVE HENAO MDSTEVE HENAO MD VASCULAR TRAUMA:VASCULAR TRAUMA: extremityextremity extremityextremity 90% of all peripheral arterial injuries occur in an90% of all peripheral arterial injuries occur in an extremityextremity civilian: upper extremitiescivilian: upper extremities military: lower extremitiesmilitary: lower extremities
  32. 32. STEVE HENAO MDSTEVE HENAO MD evaluationevaluation Hard signsHard signs: (IMMEDIATE SURGICAL: (IMMEDIATE SURGICAL EXPLORATION)EXPLORATION) observed pulsatile bleeding, arterial thrill,observed pulsatile bleeding, arterial thrill, bruit, absent distal pulse, visiblebruit, absent distal pulse, visible expanding hematomaexpanding hematoma Soft signs:Soft signs: hemorrhage by history, neurologichemorrhage by history, neurologic abnormality, diminished pulse, proximityabnormality, diminished pulse, proximity to bone injury or penetrating woundto bone injury or penetrating wound
  33. 33. STEVE HENAO MDSTEVE HENAO MD intra-arterial drugintra-arterial drug injectioninjection often neglected,often neglected, frequently misdiagnosed and mistreated arterial injuryfrequently misdiagnosed and mistreated arterial injury BRACHIAL ARTERY : most commonBRACHIAL ARTERY : most common street drugs w/ insoluble additivesstreet drugs w/ insoluble additives SITE OF INJECTION SHOULD BE LOCATED AND NOTEDSITE OF INJECTION SHOULD BE LOCATED AND NOTED injection followed by severe, unremitting paininjection followed by severe, unremitting pain accompanied by edema, numbness, discoloration, cyanosis,accompanied by edema, numbness, discoloration, cyanosis, mottlingmottling
  34. 34. STEVE HENAO MDSTEVE HENAO MD QUESTIONS?QUESTIONS? INTERESTING STORIES?INTERESTING STORIES?
  35. 35. VASCULARVASCULAR EMERGENCIESEMERGENCIES STEVE HENAO MDSTEVE HENAO MD Vascular Surgery & Vascular InterventionalVascular Surgery & Vascular Interventional RadiologyRadiology New Mexico Heart InstituteNew Mexico Heart Institute

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