Vascular trauma

2 types of vascular trauma based on the blood vessels

Central vs Peripheral( commoner)

Arterial vs Venous

Effects of arterial trauma •Bleeding

Ischemia

Epidemiology of Trauma

Males are more affected. 90%

Those aged between 20-40 yrs

Majority are peripheral vascular injuries ( 90%)

Types of haemorrhage in vascular trauma

Concealed

Chest, abdomen, Pelvis

Thigh, Buttocks

Facial Fractures-

Swallowed blood

External Leading to Acute Interruption to blood flow to organ or limbLeading to IschemiaLeading to

Oxygen supply is inadequate

Anaerobic metabolism

Lactic acid is produced

Activate humoral and cellular pathways to inflammation

Lenght of Ischemia of tissues and reperfusion

Skeletal Muscles

–Could be ischemic after 3 – 6 hrs

–Can recover after establishing circulation

Peripheral Nerves

–More sensitive

–Could be ischemic within a short period

–Prolonged neurological deficit may result

If the arterial supply is restored

Metabolites are released in to the circulation

–Potassium

–Lactic acid

–Inflammatory mediators

Leading to

Myocardial Depression

Peripheral Vasodilatation

Initiate Inflammatory response

REPERFUSION SYNDROME

Diagnosis of Vascular Trauma

In all cases => History, examination and investigations.

Presence of Hard signs

Absence of virtually exclude it

Hard signs are

–Pulsatile bleeding

–Expanding Haematoma

–Absence distal pulses

–Palpable Thrill

–Audible Bruit

Soft signs

–Peripheral nerve defect

–Moderate bleeding at the site

–Reduced but palpable pulse

–Injury to a a site of major vessel

Adjuncts to diagnosis

Pulse Oximetry-compare with the other limb;

Neither confirm nor exclude vascular injury; it can suggest the possibility

Plane X ray of fractured bone (condylar fracture is severe

Arteriogram -Conventional Arteriogram/ CT ad: can assess other structures as well. So if CT is done, arteriogram is also done with itDifficult situations in diagnosing:

High Velocity injuries

Multiple shrapnel injuries

Blunt trauma

TREATMENT OF VASCULAR TRAUMA

Presence of hard signs need immediate intervention

Site is obvious, rarely need arteriogram

Soft signs – observation; developing hard signs - ExploreTreatment 1 Explore and repair 2 Angio-embolisation 3 Endovascular therapy 4 Ligation of the vessels

Ligation of the vessels - arteries (not so important)

Common, External carotids, Subclavian, Internal iliac ,Axillary could be ligated with few complications

Internal carotid20% risk of strokes - so not ligated

External Iliac, Common femoral and Superficial femoral have significant risk of lower limb ischemiaLigation of the vessels - veins

Large veins need repair.

If difficulties all veins including IVC could be ligated – lower limb oedema in that case

Causes and Patterns and Complications of Vascular Trauma

Penetrating trauma

–Trap gun injuries

–Gun shot injuries

–Stab injuries – eg. Neck

–Endovascular procedures

-»Traumatic amputationsLeads to –Laceration – complete/ Incomplete

Blunt trauma

–Related to limb injuries associated with fractures and dislocations

–RTA

Leads to

–Crushing

–Distraction

–ShearingLeads to

»contusion of a segment

»Intimal separation

»Thrombosis – block / distal embolization

»Rupture of the vesselONE MAJOR COMPLICATION : COMPARTMENT SYNDROME •Resulting from ischemia of the compartment

Bleeding can occur in a haematoma

This can form a pseudo aneurism (because not dialated but only last layer pushed)

Distal flow will be uninterrupted

Initial diagnosis may be missed

Hence can present later

Risk of rupture

ARTERIO-VENOUS FISTULA

Injury to adjacent vein and artery

Communication occur

Can present later

Can rupture

Can compromise cardiovascular compromise

Causes and Patterns and Complications of Vascular Trauma

Penetrating trauma

–Trap gun injuries

–Gun shot injuries

–Stab injuries – eg. Neck

–Endovascular procedures

-»Traumatic amputationsLeads to –Laceration – complete/ Incomplete

Blunt trauma

–Related to limb injuries associated with fractures and dislocations

–RTA

Leads to

–Crushing

–Distraction

–ShearingLeads to

»contusion of a segment

»Intimal separation

»Thrombosis – block / distal embolization

»Rupture of the vesselONE MAJOR COMPLICATION : COMPARTMENT SYNDROME •Resulting from ischemia of the compartment

Bleeding can occur in a haematoma

This can form a pseudo aneurism (because not dialated but only last layer pushed)

Distal flow will be uninterrupted

Initial diagnosis may be missed

Hence can present later

Risk of rupture

ARTERIO-VENOUS FISTULA

Injury to adjacent vein and artery

Communication occur

Can present later

Can rupture

Can compromise cardiovascular compromise

Causes and Patterns and Complications of Vascular Trauma

Penetrating trauma

–Trap gun injuries

–Gun shot injuries

–Stab injuries – eg. Neck

–Endovascular procedures

-»Traumatic amputationsLeads to –Laceration – complete/ Incomplete

Blunt trauma

–Related to limb injuries associated with fractures and dislocations

–RTA

Leads to

–Crushing

–Distraction

–ShearingLeads to

»contusion of a segment

»Intimal separation

»Thrombosis – block / distal embolization

»Rupture of the vesselONE MAJOR COMPLICATION : COMPARTMENT SYNDROME •Resulting from ischemia of the compartment

Bleeding can occur in a haematoma

This can form a pseudo aneurism (because not dialated but only last layer pushed)

Distal flow will be uninterrupted

Initial diagnosis may be missed

Hence can present later

Risk of rupture

ARTERIO-VENOUS FISTULA

Injury to adjacent vein and artery

Communication occur

Can present later

Can rupture

Can compromise cardiovascular compromise

Major complication of vascular trauma – Ischemia

COMPARTMENT SYNDROME

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