Vascular trauma

Management of vascular trauma:

-          Trauma is a major health and social problem.

-          Fewer than 10% of patients with polytrauma have associated vascular injuries.

-          Often missed.

-          Require prompt attention, as death may result from excessive blood loss.

-          Limb salvage can be achieved by vascular repair; delay=amputation

Complex vascular injuries have a high morbidity and mortality, and a clear understanding of the pathophysiology of vascular trauma and a logical approach to the management of those injuries are essential for a favourable outcome.

Mechanism of injury:-

A.      Direct trauma

a.       Blunt

b.      Penetrating

B.      Indirect trauma

C.      Iatrogenic

a.       Angiography/ stenting/ IABP

b.      Intra-arterial drug injection

Blunt trauma-

-          Direct trauma to the artery accounts for the majority of blunt vascular injuries

-          Indirect trauma is usually the result of shearing and distraction forces following-

o   Dislocation of major joints

o   Displaced long bone fractures

o   Acceleration/ Deceleration injuries

Blunt trauma – pathomechanism-

Blunt trauma - Disruption of the intima - Thrombosis/Intimal Flap – Obstruction.

Penetrating trauma-

Partial or complete transection of vessels – bleeding/shock – impaired distal flow.

Sequelae of vascular injuries:-

A.      Acute haemorrhage

a.       Overt external bleeding

b.      Contained bleeding (eg. In muscle compartment)

c.       Concealed bleeding (eg. Pleural cavity)

B.      Hypovolaemia, Shock

C.      Haematoma with or without secondary infection

D.      Delayed bleeding or rebleeding

E.       Thrombosis: acute or delayed

F.       Ischaemia: acute or delayed

G.     Arteriovenous fistula

H.      Pseudoaneurysm formation

Types of vascular injuries:

-          Contusion

-          Puncture

-          Laceration

-          Intimal injuries

-          Partial division

-          Complete transection

-          False aneurysm

-          A-V fistula

{Do not blame the missing pulse on ‘spasm’ or ‘compartment syndrome’ }

Clinical assessment:-

History:

-          Information regarding the mechanism of the trauma, blood loss prior to hospital admission and underlying vascular disease should be obtained.

-          Resuscitation and initial management

o   ATLS guidelines

Examination:

-          Clinical signs of vascular injuries

o   Hard signs of vascular injuries:-

§  Active pulsatile bleeding

§  Shock with ongoing bleeding

§  Absent distal pulses

§  Symptoms and signs of acute ischemia

§  Expanding or pulsating haematoma

§  Bruits or thrill over the area of the injury

o   Soft signs of vascular injuries:-

§  History of severe bleeding

§  Diminished distal pulse

§  Injury of anatomically related structures

§  Small non-expanding haematoma

§  Multiple fractures and extensive soft tissue injury

§  Injury in anatomical area of major blood vessels

Examination of peripheral vessels:

-          Problems

o   Distal pulse may be difficult to appreciate in a hypotensive patient

o   Pulses may be absent in elderly due to atherosclerotic obstruction

-          Solutions

o   Always compare with opposite side

o   Record ankle pressure/ ABI

Pre hospital care:-

-          ABC of trauma

-          IV fluids- “permissive hypotension”

-          Antibiotics, Tetanus prophylaxis

-          Analgesics

-          Splinting of the extremity

-          Control of haemorrhage

-          Evacuation by fastest available means