Vascular Trauma Flashcards

(35 cards)

1
Q

State some potential causes of peripheral vascular trauma

A
  • Penetrating wounds
    • Gunshot
    • Stab
    • IV drug abuse
  • Blunt trauma
    • Joint displacement
    • Bone fracture
    • Contusion (bruise)
  • Invasive procedures
    • Arteriography
    • Cardiac catheterisation
    • Balloon valvuloplasty
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2
Q

What do we mean by hard and soft signs of arterial injury?

A
  • 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
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3
Q

State the 4 hard signs of arterial injury

A
  • External arterial bleeding
  • Rapidly expanding haematoma
  • Palpable thrill, audible bruit
  • Acute limb ischaemia (not corrected by reduction of dislocation or realignment of fracture)
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4
Q

State the 5 soft signs of arterial injury

A
  • 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
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5
Q

What investigations may be required for a pt with soft signs of arterial injury?

A
  • Serial examination
  • Duplex scan
  • Arteriography (CT or MRI)
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6
Q

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?

A
  • To prevent unnecessary operation
  • Document presence of surgical lesion
  • Localise vascular injury to plan operative approach
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7
Q

Certain limb fractures have a higher incidence of associated vascular injury; state 3

A
  • Supracondylar #humerus in children
  • High tibial ‘bumper fracture’
  • Dislocation of knee
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8
Q

State some key principles of cannula insertion and fluid resuscitation in peripheral vascular trauma

A
  • 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)
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9
Q

Discuss the general principles of management of a peripheral vascular injury in the limb

A
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10
Q

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?

A

CT scan

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11
Q

What is the most common intra-thoracic vascular injury?

Discuss its prognosis

A
  • 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
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12
Q

State some causes of retroperitoneal bleeds

A
  • Pelvic fractures
  • Surgery in the pelvis
  • Spontaneous (warfarin therapy)
  • Following angiogram/angioplasty
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13
Q

State some signs & symptoms of peritoneal bleed

A
  • 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
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14
Q

Discuss the management of retroperitoneal bleeds

A
  • Fluid resuscitation
  • Alert vascular surgeons
  • Urgetn CT to confirm diagnosis
  • Surgical repair or radiological intervention
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15
Q

Draw and label the different segments/sections of the aorta

A
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16
Q

Draw and label the aortic arch

17
Q

What is an aortic dissection?

A

Tear in the tuica intima of aorta resutling in blood flowing between, and splitting apart, the tunica intima and tunica media

18
Q

State some risk factors for aortic dissections- highlight the most important risk factor

A
  • Hypertension
  • Trauma
  • Atherosclerotic disease
  • Male
  • Connective tissue disorders e.g. Marfan’s syndrome, Ehlers-Danlos syndrome
  • Bicuspid aortic valve
  • Pregnancy
  • Syphilis
19
Q

Who are aortic dissections more common in?

*Think about gender, age and underlyiing disorders

A
  • Males
  • 50-70yrs
  • Connective tissue disorders e.g. Marfan’s, Ehlers-Danlos syndrome
20
Q

Aortic dissections can be acute or chronic; explain the difference

A
  • Acute= diagnosed =14 days
  • Chronic= diagnosed >14 days
21
Q

Discuss signs & symptoms of aortic dissection

A

Tearing chest pain that typically radiates to back

  • Tachycardia
  • Hypotension or hypertension (depending on if there is rupture)
  • New aortic regurgitation murmur
  • Pulse deficit (weak or absent carotid, brachial or femoral pulse)
  • Variation(>20mmHg) in systolic BP between arms
  • Limb ischaemia
  • Hemiplegia is carotid artery supply affected
  • Paraplegia if anterior spinal artery supply affected
  • Anuria if renal artery supply affected
22
Q

Aortic dissections can progress distally or proximally or in both directions; what do we call it if it progresses:

  • Proximally
  • Distally
A
  • Proximally: retrograde (towards aortic valve)
  • Distally: anterograde (towards iliac arteries)
23
Q

Explain how retrograde aortic dissections can cause cardiac tamponade

A
  • Retrograde propagation can result in prolapse of aortic valve
  • Bleeding in the pericardium
  • and hence cardac tamponade
24
Q

State the two systems that can be used to classify aortic dissections

A
  • Stanford
  • DeBakey

Both classify anatomically

25
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)*
26
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**
27
Summarise how Stanford and DeBakey classification of aortic dissections overlap
28
What type of shock is seen in aortic dissections?
Could be: * Hypovolaemic: due to blood loss * Cardiogenic: due to severe aortic regurgitation or pericardial tamponade
29
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)
30
What finding on CT angiogram of chest, abdo & pelvis suggests aortic dissection?
False lumen
31
Discuss the immediate management of aortic dissections (regardless of type)
* High flow oxygen * IV access (2 large bore cannulas) * CAREFUL fluid resuscitation; if hypotensive keep bp at 100-110 * Contact vascular surgery and ITU *\*if there has been a rupture then target BP should be enough for cerebral perfusion only. If it is uncomplicated dissection then target BP should be below 110mmHg*
32
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
33
Type B dissections can go on to be chronic; true or false?
True; can have continued leakage into dissection (even if stent is placed). Most common complication of chornic disease is an aneurysm.
34
State some potential complications of aortic dissections
_Complications backward tear:_ * Aortic rupture * Aortic regurgitation * Cardiac tamponade * Myocardial infarction *(inferior pattern due to RCA involvement)* _Complications of forward tear:_ * Stroke or paraplegia (if cerebral or spinal artery involvement) * Renal failure
35
What do we mean by a complicated aortic dissection?
Complications have arisen such as: * Rupture * Renal, visceral or limb ischaemia * Uncontrollable hypertension