+ All Categories
Home > Documents > APPROACH TO VASCULAR INJURY BY DR SIKHOSANA. Mechanisms of injury Penetrating Penetrating Blast...

APPROACH TO VASCULAR INJURY BY DR SIKHOSANA. Mechanisms of injury Penetrating Penetrating Blast...

Date post: 23-Dec-2015
Category:
Upload: sylvia-may
View: 218 times
Download: 0 times
Share this document with a friend
Popular Tags:
27
APPROACH TO VASCULAR INJURY BY DR SIKHOSANA
Transcript

APPROACH TO VASCULAR INJURY

BY DR SIKHOSANA

Mechanisms of injury

Penetrating Blast Blunt iatrogenic

Pathophysiology

Missile damage is related to the velocity

Shotgun causes multiple perforations and can cause embolization

Blunt trauma results from shearing or distraction

Vascular spasm occurs at or distal to the injury due to the unapposed sympathetic constriction, it is not the cause for ischaemia

Hard signs

Pulsatile bleeding Expanding haematoma Thrill or bruit Pulse deficit ischaemia

Soft signs

History of a significant bleed Small non expanding haematoma Associated nerve injury Proximity to a major vessel

Unclear presentation

Thorax injuries- suspect if there is a widened mediastinum, persistent shock, large haemothorax

Intimal injury- the pulses maybe intact but the exposed collagen is very thrombogenic

Indications for investigation: neck

Zone I and III All gunshots Suspicion post doppler of zone II

Mediastinum

Fracture of 1st,2nd ribs, sternum and scapula

Sterno clavicular joint dislocation Trans axial gunshot Widened mediastinum Obliteration of aortic notch, left apical

pleural cap, aorto-pulmonary window Left haemothorax Oesophageal and tracheal deviation to the

right Depression of left main bronchus

Limbs

Multiple fractures Multiple penetrating injuries Shotgun Knee/elbow dislocation Degloving injury Gunshot tract along the long axis of

the vessel

Imaging modalities

Duplex ultrasound Angiography CT angiography MRA

Duplex ultrasound

Combines pulsed doppler and real time B mode ultrasound imaging

Advantages- non invasive, cheap, no radiation and sensitive

Locally used for neck zone II and single peripheral injuries

Angiography

Gold standard imaging and there is a therapeutic option, although it is invasive

Features suggestive of injury- extravasation of contrast, dilatation due to intimal injury, narrowing, occlusion, filling defects and AV fistula

CT angiography

Sensitivity and specificity of 90-100% Advantage is that it is non invasive

and rapid Disadvantages – lack of therapeutic

options, artifacts from foreign bodies, streak artifacts simulating intimal tears and the imaging of the arch not good on CT

MRA

Has good sensitivity Not ideal due to the time taken for

the investigation

Bleeding control

Pressure

balloon

Management

All vascular injuries should be repaired as ASAP to avoid delayed bleeding, compressive haematoma and limb compromise

We do not believe in conservative management of minimal arterial injuries because the history is unpredictable, poor patient compliance and too late presentation of complications

Mangled extremity severity score

Skeletal/soft tissue injury Limb ischaemia Shock Age

Score of >7 is accurate for predicting eventual need for amputation

Diagnostic fasciotomy

More than 6 hours presentation

Prophylatic fasciotomy

Prolonged hypotension Extensive soft tissue injury Arterial and venous injury Bone plus vascular injury Delayed vascular repair Inability to assess the patient, e.g.

head/spinal injury

Therapeutic fasciotomy

Increased tissue turgor Extensive deep haematoma in the

presence of ischaemia

FASCIOTOMY BEFORE VASCULAR REPAIR

Principles of vascular repair

Digital or sponge pressure and catheter to control bleeding

Prophylatic antibiotics Access available to the groin for the graft Wide exposure with proximal and distal

control Edges debrided to healthy intima Embolectomy and flushing with heparin

saline Vascular repair before ortho Adequate tissue cover of the vascular

repair

Techniques of repair

Lateral – for wide calibre vessels Patch- to prevent stenosis End to end- single tethering stitch

should hold and < 4mm vessel should have interrupted sutures

Interposition graft- NB similar size with the injured vessel

Ligation- gross contamination and unstable patient

Types of grafts

Vein- no cost and low infection rate Arterial- same advantages as the

vein but the donor site may need to be replaced

Synthetic- ? Higher infection risk, expensive and poor patency across joints

Causes of graft thrombosis

In flow

Anastomosis – intimal injury, adventitia, tension, stenosis, poor graft

Run off

Primary amputation

Dead leg

2 or more dead compartments

Mangled limb

Endovascular

Embolisation

Stenting

Balloon occlusion

Conclusion

All vascular injuries should be repaired as soon as they are identified

We do not have enough man power to treat minimal injuries consevatively


Recommended