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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