Vascular Trauma Flashcards
State some potential causes of peripheral vascular trauma
- Penetrating wounds
- Gunshot
- Stab
- IV drug abuse
- Blunt trauma
- Joint displacement
- Bone fracture
- Contusion (bruise)
- Invasive procedures
- Arteriography
- Cardiac catheterisation
- Balloon valvuloplasty
What do we mean by hard and soft signs of arterial injury?
- Hard signs= indicate presence of major vascular injury therefore immediate surgery is required
- Soft signs= indicate there might be a major vascular injury hence additional observation & diagnostic tests are required
State the 4 hard signs of arterial injury
- External arterial bleeding
- Rapidly expanding haematoma
- Palpable thrill, audible bruit
- Acute limb ischaemia (not corrected by reduction of dislocation or realignment of fracture)
State the 5 soft signs of arterial injury
- History of bleeding at the scene
- Proximity of penetrating wound or blunt trauma to major artery
- Diminished unilateral pulse
- Small non-pulsatile haematoma
- Neurogenic deficit
What investigations may be required for a pt with soft signs of arterial injury?
- Serial examination
- Duplex scan
- Arteriography (CT or MRI)
We have said that soft signs of arterial injury indicate there may be a major vascular trauma. Why are diagnostic studies done when a pt has soft signs of arterial injury?
- To prevent unnecessary operation
- Document presence of surgical lesion
- Localise vascular injury to plan operative approach
Certain limb fractures have a higher incidence of associated vascular injury; state 3
- Supracondylar #humerus in children
- High tibial ‘bumper fracture’
- Dislocation of knee
State some key principles of cannula insertion and fluid resuscitation in peripheral vascular trauma
- Gain adequete IV access (two large bore cannulas)
- Place lines into an uninjured upper or lower extremity
- Avoid placing cannulas into extremities as this will lead fluid directly to areas of tamponade or venous injury
- Preserve saphenous or cephalic veins (may be needed for repair)
Discuss the general principles of management of a peripheral vascular injury in the limb
Blunt injuries to major intrathoracic vascular structures present as a major challenge in both diagnosis and management. May require immediate management for tension pneumothorax and/or tamponade. If the pt is stable, what imaging would we do to help identify the arterial trauma?
CT scan
What is the most common intra-thoracic vascular injury?
Discuss its prognosis
- Disruption of the descending thoracic aorta at its isthmus- caused by rapid deceleration
- Prognosis:
- 90% die before reach hospital
- Of those reaching hospital 25% die within first 24hrs
State some causes of retroperitoneal bleeds
- Pelvic fractures
- Surgery in the pelvis
- Spontaneous (warfarin therapy)
- Following angiogram/angioplasty
State some signs & symptoms of peritoneal bleed
- Hypotension or drop in Hb
- Lower back pain
- May have iliac fossa mass/tenderness
- History of cause of peritoneal bleed e.g. had cardiac catheterisation
Discuss the management of retroperitoneal bleeds
- Fluid resuscitation
- Alert vascular surgeons
- Urgetn CT to confirm diagnosis
- Surgical repair or radiological intervention
Draw and label the different segments/sections of the aorta
Draw and label the aortic arch
What is an aortic dissection?
Tear in the tuica intima of aorta resutling in blood flowing between, and splitting apart, the tunica intima and tunica media
Describe the Stanford classifcation of aortic dissections
- Group A: involves ascending aorta and can propagate to aortic arch and descending aorta. Tear can originate anywhere along this path (⅔ of cases)
- Group B: descending aorta distal to left subclavian origin (⅓ cases)
Describe the DeBakey classification of aortic dissections
- Type 1: originates in ascending aorta and propagates at least to the aortic arch (typically in pts >65yrs and carries highest mortality)
- Type 2: originates in and is confined to the ascending aorta (typically in elderly pts with hypertension & atherosclerotic disease)
-
Type 3: originates distal to the subclavian artery in the descending aorta
- 3a= extends to diaphragm
- 3b= extends into abdominal aorta
Summarise how Stanford and DeBakey classification of aortic dissections overlap
What investigations would you do if you suspect a pt has an aortic dissection, include:
- Bedside
- Bloods
- Imaging
Bedside
- ECG: cardiac pathology
- ABG
Bloods
- FBC:
- U&Es:
- LFTs:
- Troponin:
- Coagulation:
- Crossmatch at least 10 units (according to oxford handbook)
Imaging
- CT angiogram of chest, abdomen & pelvis (INVESTIGATION OF CHOICE)
- Consider transoesophageal echo (if pt too unstable to go to CT)
- CXR may show widened mediastinum (not most useful)
What finding on CT angiogram of chest, abdo & pelvis suggests aortic dissection?
False lumen
Discuss the management (following initial management) of:
- Type A dissections
- Type B dissections- uncomplicated
- Type B dissections- complicated
- Stanford type A: replace with synthetic graft
- Stanford type B- uncomplicated: medical management with beta blockers to decrease BP and Hr to minimise stress of dissection and limit propagation
- Stanford type B- complicated: surgical repair e.g. with stent
