Download - Vastrauma mannar
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Vascular TraumaJoel Arudchelvam
Consultant Vascular and Transplant Surgeon Teaching Hospital Anuradhapura
Sri Lanka.
Mannar Medical AssociationMonthly Clinical Meeting
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Vascular trauma /injury
• Injury to – Arteries– Veins
• Anatomical regions– Extremity – limbs– Abdomen and pelvis– Thorax– Head and neck
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Vascular trauma /injury
• Injury to – Arteries– Veins
• Anatomical regions– Extremity – limbs– Abdomen and pelvis– Thorax– Head and neck
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Extremity Vascular Injuries
• Unexpected
• Young and fit
• Results in limb loss at times loss of life
• Loss of earning capacity
• Economic burden
• Our experience (2011/2012 – NHSL)– Popliteal arterial injury - 34.8% amputation rate.
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Causes
• Road Traffic Accidents – 38.5%• Trap Gun – 7.5%• Home Accidents - 7.5%• Cuts and Stabs• Iatrogenic - 46.1%
Mechanism of injury• Sharp / penetrating• Blunt
Data from Teaching Hospital Anuradhapura Sri Lanka 2015 - 2016
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Mechanism of disruption of flow at arterial level
• Transection
• Laceration
• Contusion
• Kink
• Intimal flap
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Vascular traumaSigns of a 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
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Signs of a vessel 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.
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Problems with diagnosing ischaemia after trauma
• Pain – Due to injury itself
• Pallor – Pallor due to blood loss
• Absent pulse– Absent due to low blood pressure. Compare with othe l
imb
• Paresthesia , paresis – Due to associated nerve, muscle injury or unresponsive patient
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Investigations
Investigations
•Hard signs
• Urgent intervention
•Soft signs
• Observe• Investigate
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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
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Investigations
• Angiography– CT angiography– Catheter angiography
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CT ANGIOGRAPHY
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3D Reconstruction
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Conventional angiography / DSA
• Contrast directly into artery• Traumatic • DSA – Digital subtraction angiography
– done though a software after obtaining initial images
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Conventional angiography / DSA
• Contrast directly into artery• Traumatic • DSA – Digital subtraction angiography
– done though a software after obtaining initial images
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Investigations
• Arteriography
– On table / DSA – for multi level injury
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Investigations
• Patient presenting with– Soft signs– Delayed presentation– Avf– False aneurysm
– Pre-op angiography
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How soon we should we repair – As soon as possible– Effects of ischaemia
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How soon we should we repair
• At Teaching Hospital Anuradhapura 2015- 2016;
• – 1 year– 13 cases– Commonest artery popliteal 53.8 %– Mean ischaemic time – 12.67 hrs– 4 clinically dead limb (mean time 15.75 hrs)
Data from Teaching Hospital Anuradhapura Sri Lanka 2015 - 2016
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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
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Surgical repair (cont..)• Balloon thrombectomy• Systemic and distal heparinisation• Interposition graft / Direct
approximation– Unit experience – 88.2% RSVG
• Prosthesis – lower patency– infection
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Surgical repair (cont..)
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Principles of arterial repair
• Cut / laceration _ suture transversely• Heparin – depends on clinical situation
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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
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Primary Amputation • Extensive crush injuries and soft
tissue damage – “mangled limb”• No need to transfer – discuss / photo
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Shunting
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Compartment syndrome
Recognize
Remove the cause
Surgery – fasciotomy
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Compartment Syndrome
Treatment – Fasciotomy
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In hospitals where facilities for repair is not available
• ABCD • Fasciotomy • Discuss• Transfer• Do not apply tight dressings
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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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Thank You