Vascular trauma symposium December 2017

transcript

Vascular TraumaJoel Arudchelvam

Consultant Vascular and Transplant Surgeon Teaching Hospital Anuradhapura.

Vascular trauma /injury

• Injury to – Arteries– Veins

• Anatomical regions– Extremity – limbs– Abdomen and pelvis– Thorax– Head and neck

Vascular trauma /injury

• Injury to – Arteries– Veins

• Anatomical regions

– Extremity – limbs– Abdomen and pelvis

– Thorax– Head and neck

• 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

• Reduced movements

• Numbness

• BP – 80 / 50 mm / Hg

• Clinical evidence of fracture around knee joint

• Is there an arterial injury ?

• Why ?

• What are the signs and symptoms?

Mechanism of disruption of flow at arterial level

• Transection

• Laceration

• Contusion

• Kink

• Intimal flap

Vascular traumaSigns of a vessel injury• Hard signs

• Soft sign

Hard signs– Active bleeding

– Signs of distal ischaemia

• Absent pulse

• Pain

• Pale

• Perishing Cold

• Paresthesia / anaesthesia

• Paresis / Paralysis – Expanding hematoma

– Thrill, Bruits

Signs of a vessel injury• Soft signs

– Hematoma– Injury close to a known neurovascular bundle– Reduced pulse

• Is this late?

• Will you Repair?

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.

• What are the alternative explanations for the above signs and symptoms

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

• Paresthesia , paresis – occur due to associated nerve, muscle injury or

unresponsive confused patient

• What do you do ?

– Resuscitate

– Explore immediately

– Resuscitate

– Explore immediately– ? fasciotomy

– Resuscitate

– Explore immediately– ? fasciotomy– Investigate

• Two units of blood transfused

• BP – 110 / 70

• No distal pulse

• Now what

• Any investigations ?

Investigation

• Hard signs – Resuscitate and explore

• Soft sign – Can investigate

• What other investigations are available?

Investigations

•Hard signs

• urgent intervention

•Soft signs

• Observe• Investigate

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

Investigations

• Angiography– CT angiography– Catheter angiography

CT ANGIOGRAPHY

3D Reconstruction

Conventional angiography / DSA

• Contrast directly into artery

• Traumatic

• DSA – Digital subtraction angiography– done though a software after obtaining initial

images

Conventional angiography / DSA

• Contrast directly into artery

• Traumatic

• DSA – Digital subtraction angiography– done though a software after obtaining initial

images

Investigations

• Arteriography

– On table / DSA –

for multi level injury

Investigations

• Patient presenting with– Soft signs– Delayed presentation– Avf– False aneurysm

– Pre-op angiography

• In this patient – What investigations you

would request

How soon we should we repair – As soon as possible– Effects of ischaemia

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)

• Will he need fasciotomy ?

WHAT ARE THE LEG COMPARTMENTS

LEG COMPARTMENTS

FASCIOTOMY

Fasciotomy

• 3 compartments dead

• Distal pulse absent

• Will you repair the artery ?

Surgical Repair

• Exploration done

• Contused artery

• What re the principles of repair

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

Surgical repair (cont..)• Balloon thrombectomy• Systemic and distal heparinisation• Interposition graft / Direct

approximation– Unit experience – 88.2% RSVG

• Prosthesis – lower patency

– infection

Surgical repair (cont..)

Principles of arterial repair

• Cut / laceration _ suture transversely

• Heparin – depends on clinical situation

Reperfused ..

• Tachycardia

• Transient lowering of blood pressure

• Recovered with fluid resuscitation

• Mannitol given

• At ICU alkaline diuresis

POST PERFUSION EFFECTS

• REPERFUSION INJURY

• REPERFUSION SYNDROME

• Local – reperfusion injury– Paradoxycal death of already dying muscles after

reperfusion

• Systemic- Reperfusion syndrome– Hypotension– ARDS– Lactic acidosis– Hyperkalemia– Renal failure

Reperfusion effects

• Fasciotomy

• Hydrate the patient

• Mannitol

• O2

• Inotropes

• Ligation of vessel if not responding to above mesures

• Bicarbonate diuresis

Reperfusion syndrome- Management

• 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

What else can we do

• Compartment excision ?

• Ligation

• Amputation

Fracture

• What about bone

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

• Do you repair all injuries

Primary Amputation • Extensive crush injuries and soft

tissue damage – “mangled limb”

• No need to transfer – discuss / photo

• What will you do if threre are no facilities to repair

In hospitals where facilities for repair is not available

• ABCD • Fasciotomy • Discuss• Transfer• Do not apply tight dressings• ? shunt

Summary

• Vascular injury;

– Resuscitate

– Assess viability and extent of injury

– Assess need for fasciotomy

– Early intervention and post intervention monitoring

– Rehabilitation

Thank You

Vascular trauma symposium December 2017

Health & Medicine