Vascular Trauma by Joel Arudchelvam

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Vascular Trauma

• Joel Arudchelvam

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Types of injury source

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

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Types arterial damage

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

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Presentation

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

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Clinical

• 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

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Distal ischaemia

• 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.

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Hard / Soft signs

• 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

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Problems with diagnosing distal ischaemia after
trauma

• 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

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Investigations

• 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

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Investigations

• 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

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Management

• ABCD
• Urgent exploration
• Repair - Direct, interposition graft
• Ligation non important arteries and as a damage
  control procedure

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In hospitals wherefacilities for repair is not
available

• Urgent transfer after stabilisingABCD
• FASCIOTOMY

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Complications

• Ischemia reperfusion injury
• Compartment syndrome
• Arteriovenous fistula
• False aneurysm
• Death

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Ischemic and Reperfusion injuries

• 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

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Ischemic and Reperfusion injuries

• 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

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Prevention and treatment

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

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Compartment syndrome

• 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

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Compartments of lower limb
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Prevention and treatment

• Early revascularisation
• Elevation
• Fasciotomy

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Single incision Fasciotomy
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• Thank You