Vascular Emergencies

VASCULARVASCULAR
EMERGENCIESEMERGENCIES
STEVE HENAO MDSTEVE HENAO MD
Vascular Surgery & Vascular InterventionalVascular Surgery & Vascular Interventional
RadiologyRadiology
New Mexico Heart InstituteNew Mexico Heart Institute

ACUTE LIMB ISCHEMIAACUTE LIMB ISCHEMIA
SUDDENSUDDEN DETERIORATION OF THE ARTERIALDETERIORATION OF THE ARTERIAL
SUPPLYSUPPLY
CAUSESCAUSES
TRAUMATRAUMA
IATROGENICIATROGENIC
EMBOLISMEMBOLISM
THROMBOSISTHROMBOSIS

EMBOLISMEMBOLISM
from the Greekfrom the Greek embolosembolos,, or “plug”or “plug”
usually occurs in otherwise normal arteriesusually occurs in otherwise normal arteries

ThrombosisThrombosis
““blood clotting within an artery”blood clotting within an artery”
progressiveprogressive atherosclerotic obstructionatherosclerotic obstruction
hypercoagulabilityhypercoagulability
aortic or arterial dissectionaortic or arterial dissection

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

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

physicalphysical
““P’sP’s””
pain, pallor, paresis, pulse deficit, paresthesia,pain, pallor, paresis, pulse deficit, paresthesia,
poikilothermypoikilothermy

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

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

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

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

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

BCVIBCVI

BCVIBCVI
•
16 slice16 slice CTACTA has been validated as the primaryhas been validated as the primary
screening modality for BCVIscreening modality for BCVI

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.

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.

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.

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

BAIBAI
CXRCXR
subxiphoid ultrasoundsubxiphoid ultrasound
multi - slice CTAmulti - slice CTA
ONCE DIAGNOSIS IS MADE = IMMEDIATEONCE DIAGNOSIS IS MADE = IMMEDIATE
SURGERYSURGERY

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

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)

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%

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

•
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

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

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

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

QUESTIONS?QUESTIONS?
INTERESTING STORIES?INTERESTING STORIES?

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