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
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
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
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)
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
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
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
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