VASCULAR TRAUMA

W. Binafsihi

RSPAD RSPAD Gatot Soebroto

Jakarta

combined

vascular-skeletal

trauma

0.2% of all trauma

10%-15% blunt limb vascular trauma

Howe, Am Surg 1987;53-205

10%-15% blunt limb vascular trauma

0.3%-3% limb arterial injury of all FXs

10%-70% amputation rate

Attebery, J A C S 1996;183:377

89MF/10yrs rural 10.000sqmiles

Traffic 33%

Farm/Industrial 16%

Gun, knives etc 51%

Kolvunen D

34% arteriography

13 1oamputations

6 2oamputations

12.4% complication

Surgery 1982; 91(6):723-727

Kolvunen D

Nichols K

Silver D

University of Missouri

Health Sciences Center

U.S.A.

12.4% complication

5.6% mortality

vascular trauma

time

mechanism

PROGNOSTIC FACTORS FOR LIMB SALVAGE

mechanism

anatomic location

associated injuries

physiologic health

clinical presentation

SEQUENCE

history

clinical

noninvasive

intraop invasive

postop invasive

vascular trauma

free radicals

neutrophils

degraded arachidonic acids

MOLECULAR BIOLOGIC MILLEU

degraded arachidonic acids

RENAL

LIVER

CARDIAC

LUNGS

posterior knee dislocation

30%-60% popliteal arterial injury

20%-50% amputation rate

Frykberg, Surg Clin N A 2002;82:67-89

20%-50% amputation rate

vascular trauma

NEUROLOGIC deficit

SOFT SIGNS

LIMITED hematoma

HISTORY OF hemorrhage

CONTRALATERAL strong pulses

vascular trauma

ABSENT pulses

BRUIT/thrill

PULSATILE hematoma

ACTIVE hemorrhage

HARD SIGNS

ACTIVE hemorrhage

DISTAL ischaemia pain

pallor

paralysis

paraesthesia

poikilothermia

vascular trauma

life threathening associated injuries

extremity reperfusion

skeletal stabilization

MANAGEMENT PRIORITIES

skeletal stabilization

soft tissue: debridement

hemostasis

nerve & tendon

irrigation

wound coverage

skeletal-vascular trauma

perfusion is sine qua non

minimizes delay to maximize salvage

mostly negligible incidence

RATIONALE PRIORITIES

mostly negligible incidence

(of initial vascular disruption)

LIMB SURVIVAL/FUNCTIONS

combined vascular-skeletal trauma

19 amputations skeletal 60%

vascular 9%

J Trauma 1983;23:279

35 amputations skeletal 36.5%

vascular 16.6%

J Cardiovasc Surg 1979;20:473

combined vascular-skeletal trauma

interval to revascularization

skeletal 273 minutes

vascular 137 minutes

J Trauma 2003;54:211

vascular 137 minutes

combined efforts

exposure for proximal and distal control

vessel debridement

distal thrombectomy

distal heparin flush

REPERFUSION CONSIDERATONS

distal heparin flush

RESTORE FUNCTION intraluminary shunt

vascular repair

FASCIOTOMYcompletion arteriography

full thickness tissue coverage

Ruptur a.Femoralis Superfisial IRuptur a.Femoralis Superfisial I

Repair & GraftRepair & Graft

PascaPasca--repair & graftrepair & graft

Infeksi pasca iskemiaInfeksi pasca iskemia

1963

Thomas J. FogartyThomas J. Fogarty

1963