VASCULAR INJURIES involving various structure

Vascular injury

1. VASCULAR INJURIES

2. why they are IMPORTANT ..?? They are emergent Technically demanding to treat Several treatment modalities Altered physiology of the patient

3. CAUSES RTA STAB INJURIES SELF FALL / BUILDING COLLAPSE SUICIDAL ATTEMPT UNINTENTIONAL CUT INJURIES CUT THROAT / DOMESTIC VIOLENCE HOSPITAL ACQUIRED COMBAT INJURIES ATHLETIC INJURIES

4. IMPLICATIONS OF INJURIES Major vessel injury - life threatening Minor peripheral vessel injury - limb threatening

5. TYPES

6. TYPES

7. TYPES

8. TYPES

9. TYPES

10. ASSESSMENT ABC

11. CHECKLIST 1. High-risk mechanism of injury • Significant blunt-force loading and anatomic extent across major vessels? • Penetrating path in area of major vessels (i.e., proximity)? 2 . Blood loss at the scene • History of pulsatile bleeding from the wound? • Significant blood at the scene, on clothing, or trail of blood? • Fled the scene and history of significant bleeding from wounds? 3. Bleeding indicators • Prehospital hypotension present and trauma in the area of a major vessel? • Prehospital shock index (HR/SBP) >0.90? • Shock unexplained, with nonbleeding extremity or neck lacerations

12. Contd.. 4 . Physical Examination • Pulsatile bleeding, copious venous bleeding, or large hematoma? • Absent extremity pulses, absent Doppler signals, anklebrachial or injured extremity of index <0.9? • Bruit or thrill over injury site? • Major deficit in peripheral nerve located in proximity to major vessel? 5. High-risk fractures or joint dislocations ? • Cervical spine fracture—vertebral artery injury • Thoracic spine fracture—thoracic aortic injury • Supracondylar humerus fracture—brachial artery injury • Knee dislocation— popliteal artery injury • Tibial plateau fracture—below-knee popliteal artery injury and/or leg compartment syndrome

13. ASSESSMENT Is this blunt or penetrating injury ? Is this Arterial or Venous injury ? Should I take the patient to the operating room or do further investigations? Is it Hospital Vs community based vascular injury?

14. ASSESSMENT ARTERIAL OR VENOUS Hard signs of Arterial Injury Pulsatile external bleeding Absent distal pulses. Expanding hematoma Distal ischemia Thrill or bruit Arterial pressure index < 0.9

15. SOFT SIGNS History of hemmorhage Wounds of neck or extremities Unexplained hemorrhagic shock Neurological deficit in peripheral nerve in proximity to vessels High risk fracture,dislocation or penetrating proximity wound

16. ASSESSMENT ARTERIAL OR VENOUS Signs of Venous Bleed * Low pressure dark blood external bleeding * Non-expanding hematoma * Shock is rare unless associated with arterial bleed

17. ACT Start on 2 large bore IV lines Start on IV crystalloids Collect blood samples for investigations ( bld grouping and cross matching) eFAST Doppler ultrasound

18. ACT PRESSURE PACK PATIENCE

19. ACT Look out for HARD SIGNS of Arterial injury Look our for other associated injuries

20. MANAGEMENT PROTOCOL

21. LIGATION OF VESSELS Small caliber vessels especially veins can be ligated Almost all veins including the IVC can be ligated when necessary

22. CLEARING THE PTS.. HEAD AND NECK • Absence of high-risk mechanism • Normal neurologic examination • Negative physical examination of the head and neck • Absence of cervical spine or basilar skull fractures CHEST AND ABDOMEN • Normal chest and abdominal examination • Absence of high-risk mechanism • Normal chest and pelvis x-rays and negative FAST

23. CONTD.. UPPER EXTREMITY • Alert, hemodynamically stable patient • Normal upper extremity neurovascular examination • If upper extremity fracture or penetrating proximity injury: • Absence of significant hematoma or hemorrhage • Absence of neurologic deficit in distal arm or hand • Normal pulse examination or wrist pressure index ≥ 0.9 LOWER EXTREMITY • Alert, hemodynamically stable patient • Normal lower extremity neurovascular examination • If lower extremity fracture or penetrating proximity injury: • Absence of significant hematoma or hemorrhage • Absence of neurologic deficit in distal leg or foot • Normal pulse examination or ankle pressure index ≥ 0.

24. A WORD OF CAUTION