vascular emergencies
DESCRIPTION
an introductory discussion of vascular emergencies for the first responderTRANSCRIPT
VASCULAR VASCULAR EMERGENCIESEMERGENCIESSTEVE HENAO MDSTEVE HENAO MDVascular Surgery & Vascular Interventional Vascular Surgery & Vascular Interventional RadiologyRadiology
New Mexico Heart InstituteNew Mexico Heart Institute
STEVE HENAO MDSTEVE HENAO MD
ACUTE LIMB ACUTE LIMB ISCHEMIAISCHEMIA
SUDDENSUDDEN DETERIORATION OF THE ARTERIAL DETERIORATION OF THE ARTERIAL SUPPLY SUPPLY
CAUSESCAUSES
TRAUMATRAUMA
IATROGENICIATROGENIC
EMBOLISMEMBOLISM
THROMBOSISTHROMBOSIS
STEVE HENAO MDSTEVE HENAO MD
EMBOLISMEMBOLISM
from the Greek from the Greek embolosembolos, , or “plug”or “plug”
usually occurs in otherwise normal arteriesusually occurs in otherwise normal arteries
STEVE HENAO MDSTEVE HENAO MD
ThrombosisThrombosis
““blood clotting within an artery”blood clotting within an artery”
progressiveprogressive atherosclerotic obstruction atherosclerotic obstruction
hypercoagulabilityhypercoagulability
aortic or arterial dissectionaortic or arterial dissection
STEVE HENAO MDSTEVE HENAO MD
Clinical PresentationClinical Presentation
acute ischemia affects acute ischemia affects sensorysensory nerves first nerves first
motormotor nerves nerves
skinskin
muscle tissuemuscle tissue
muscle tenderness is one of the end-stage muscle tenderness is one of the end-stage signssigns
STEVE HENAO MDSTEVE HENAO MD
historyhistory
DURATION OF SYMPTOMSDURATION OF SYMPTOMS IS THE MOST IS THE MOST IMPORTANT PART OF THE HXIMPORTANT PART OF THE HX
irreversible muscle necrosis in irreversible muscle necrosis in 6 - 8 hours6 - 8 hours
STEVE HENAO MDSTEVE HENAO MD
physicalphysical
““P’sP’s””
pain, pallor, paresis, pulse deficit, pain, pallor, paresis, pulse deficit, paresthesia, poikilothermyparesthesia, poikilothermy
STEVE HENAO MDSTEVE HENAO MD
Initial managementInitial management
immediate anticoagulation with immediate anticoagulation with heparinheparin
leg stabilizationleg stabilization
prevent deteriorationprevent deterioration
O2O2 by facemask by facemask
improve skin perfusionimprove skin perfusion
IVFIVF resucitation resucitation
catheter monitoring for urine outputcatheter monitoring for urine output
analgesiaanalgesia
STEVE HENAO MDSTEVE HENAO MD
VASCULAR TRAUMAVASCULAR TRAUMA- head and neck- head and neck
Penetrating injuriesPenetrating injuries
80% of deaths are 80% of deaths are strokestroke related related
STEVE HENAO MDSTEVE HENAO MD
Clinical presentationClinical presentation
Neck classically divided into Neck classically divided into “zones”“zones”
IIIIII: above the angle of the : above the angle of the mandiblemandible
IIII: between cricoid and : between cricoid and mandiblemandible
most common (47%)most common (47%)
II: below cricoid: below cricoid
STEVE HENAO MDSTEVE HENAO MD
evaluationevaluation
Hard signsHard signs: : 97% have a vascular injury97% have a vascular injury
shock, refractory hypotension, pulsatile shock, refractory hypotension, pulsatile bleeding, bruit, enlarging hematoma, loss bleeding, bruit, enlarging hematoma, loss of pulse with stable or evolving of pulse with stable or evolving neurologic deficitneurologic deficit
Soft signs: Soft signs: only 3% have a vascular injuryonly 3% have a vascular injury
hx of bleeding at scene, stable hx of bleeding at scene, stable hematoma, nerve injury, proximity of the hematoma, nerve injury, proximity of the injury track, unequal arm BPsinjury track, unequal arm BPs
STEVE HENAO MDSTEVE HENAO MD
STEVE HENAO MDSTEVE HENAO MD
BCVIBCVI
““blunt cerebrovascular injury”blunt cerebrovascular injury”
less than 1% of all admissions for blunt traumaless than 1% of all admissions for blunt trauma
stroke rates range from 25 to 58%stroke rates range from 25 to 58%
mortality rates 31 to 59%mortality rates 31 to 59%
many patients initially asymptomaticmany patients initially asymptomatic
can develop symptoms from 1 hr to many weekscan develop symptoms from 1 hr to many weeks
screeningscreening
STEVE HENAO MDSTEVE HENAO MD
BCVIBCVI
STEVE HENAO MDSTEVE HENAO MD
BCVIBCVI• 16 slice 16 slice CTACTA has been validated as the primary has been validated as the primary
screening modality for BCVIscreening modality for BCVI
STEVE HENAO MDSTEVE HENAO MD
BCVIBCVI• The mainstay of treatment for BCVI is The mainstay of treatment for BCVI is
antithrombotic therapyantithrombotic therapy
• If the patient has no contraindications to If the patient has no contraindications to anticoagulation, a prudent protocol would be anticoagulation, a prudent protocol would be heparin therapy (goal, activated partial heparin therapy (goal, activated partial thromboplastin time of 50 to 60 seconds) and thromboplastin time of 50 to 60 seconds) and transition to warfarin (goal, international transition to warfarin (goal, international normalized ratio of 2.0) for 3 months. normalized ratio of 2.0) for 3 months.
• Antiplatelet therapy should be used for the same Antiplatelet therapy should be used for the same period.period.
STEVE HENAO MDSTEVE HENAO MD
Subclavian InjurySubclavian Injury
• Injuries to the thoracic outlet are often lethal.Injuries to the thoracic outlet are often lethal. Prehospital mortality is 50% to 80%, and of Prehospital mortality is 50% to 80%, and of those patients who survive transport, 15% die those patients who survive transport, 15% die during treatment.during treatment.
• long-term morbidity may be secondary to long-term morbidity may be secondary to brachial plexus injuries.brachial plexus injuries.
• Endovascular treatmentEndovascular treatment in this area can in this area can obviate the need for extensive dissection at obviate the need for extensive dissection at the base of the neck.the base of the neck.
STEVE HENAO MDSTEVE HENAO MD
STEVE HENAO MDSTEVE HENAO MD
Cervical Venous InjuriesCervical Venous Injuries
• If the patient has hard signs of a vascular If the patient has hard signs of a vascular injury and is in extremis, injury and is in extremis, the neck and the neck and subclavian veins can be ligated with limited subclavian veins can be ligated with limited morbiditymorbidity..
• If the internal jugular vein is ligated, the If the internal jugular vein is ligated, the patient should be monitored for patient should be monitored for cerebral cerebral edemaedema; however, this is a rare occurrence, ; however, this is a rare occurrence, even with bilateral internal jugular vein even with bilateral internal jugular vein ligation.ligation.
STEVE HENAO MDSTEVE HENAO MD
VASCULAR TRAUMA:VASCULAR TRAUMA:thoracicthoracic
BLUNT AORTIC INJURYBLUNT AORTIC INJURY
80% caused by MVC80% caused by MVC
head-on collisions - most commonhead-on collisions - most common
pts young - mean age: 39pts young - mean age: 39
9% survival at scene/ 9% survival at scene/ 98% overall mortality98% overall mortality
substance abuse is a factor in 40%substance abuse is a factor in 40%
seat belt use decreases risk by a factor of 4seat belt use decreases risk by a factor of 4
ejection from vehicle doubles the riskejection from vehicle doubles the risk
STEVE HENAO MDSTEVE HENAO MD
BAIBAI
CXRCXR
subxiphoid ultrasoundsubxiphoid ultrasound
multi - slice CTAmulti - slice CTA
ONCE DIAGNOSIS IS MADE = IMMEDIATE ONCE DIAGNOSIS IS MADE = IMMEDIATE SURGERYSURGERY
STEVE HENAO MDSTEVE HENAO MD
VASCULAR TRAUMA:VASCULAR TRAUMA:abdominalabdominal
penetrating trauma responsible for 90% of penetrating trauma responsible for 90% of abdominal vascular injuriesabdominal vascular injuries
LOW VELOCITY: DIRECT INJURY TO VESSELLOW VELOCITY: DIRECT INJURY TO VESSEL
HIGH VELOCITY: SHOCK WAVE/TRANSIENT HIGH VELOCITY: SHOCK WAVE/TRANSIENT CAVITATIONCAVITATION
STEVE HENAO MDSTEVE HENAO MD
blunt abdominal traumablunt abdominal trauma
rapid deceleration (MVC, falls)rapid deceleration (MVC, falls)
direct AP crushing (seat belt, direct blows)direct AP crushing (seat belt, direct blows)
direct laceration by bone fragment (severe direct laceration by bone fragment (severe pelvic fx)pelvic fx)
STEVE HENAO MDSTEVE HENAO MD
STEVE HENAO MDSTEVE HENAO MD
common vessels injuredcommon vessels injured
IVC : 25%IVC : 25%
Aorta : 21%Aorta : 21%
Iliac arteries : 20%Iliac arteries : 20%
Iliac veins : 17%Iliac veins : 17%
superior mesenteric vein :11%superior mesenteric vein :11%
superior mesenteric artery : 10%superior mesenteric artery : 10%
STEVE HENAO MDSTEVE HENAO MD
Prehospital treatmentPrehospital treatment
Rapid transportation to Trauma CenterRapid transportation to Trauma Center
““SCOOP AND RUN”SCOOP AND RUN”
‘‘CONTROLLED HYPOTENSIONCONTROLLED HYPOTENSION’’
trying to balance exanguination against trying to balance exanguination against cardiac arrestcardiac arrest
Immediate surgical control of the bleedingImmediate surgical control of the bleeding
STEVE HENAO MDSTEVE HENAO MD
• Computed tomography (CT) has little or no role Computed tomography (CT) has little or no role in suspected vascular injuries resulting from in suspected vascular injuries resulting from penetrating traumapenetrating trauma during the acute stage. during the acute stage. However, it may play a useful role in blunt However, it may play a useful role in blunt trauma by identifying large hematomas, false trauma by identifying large hematomas, false aneurysms, or vessel occlusionsaneurysms, or vessel occlusions
STEVE HENAO MDSTEVE HENAO MD
STEVE HENAO MDSTEVE HENAO MD
STEVE HENAO MDSTEVE HENAO MD
STEVE HENAO MDSTEVE HENAO MD
VASCULAR TRAUMA:VASCULAR TRAUMA:extremityextremity
90% of all peripheral arterial injuries occur in 90% of all peripheral arterial injuries occur in an extremityan extremity
civilian: upper extremitiescivilian: upper extremities
military: lower extremitiesmilitary: lower extremities
STEVE HENAO MDSTEVE HENAO MD
evaluationevaluation
Hard signsHard signs: (IMMEDIATE SURGICAL : (IMMEDIATE SURGICAL EXPLORATION)EXPLORATION)
observed pulsatile bleeding, arterial observed pulsatile bleeding, arterial thrill, bruit, absent distal pulse, visible thrill, bruit, absent distal pulse, visible expanding hematomaexpanding hematoma
Soft signs: Soft signs:
hemorrhage by history, neurologic hemorrhage by history, neurologic abnormality, diminished pulse, proximity abnormality, diminished pulse, proximity to bone injury or penetrating woundto bone injury or penetrating wound
STEVE HENAO MDSTEVE HENAO MD
intra-arterial drug intra-arterial drug injectioninjection
often neglected, often neglected, frequently misdiagnosed and mistreated arterial frequently misdiagnosed and mistreated arterial injuryinjury
BRACHIAL ARTERY : most commonBRACHIAL ARTERY : most common
street drugs w/ insoluble additivesstreet drugs w/ insoluble additives
SITE OF INJECTION SHOULD BE LOCATED AND NOTEDSITE OF INJECTION SHOULD BE LOCATED AND NOTED
injection followed by severe, unremitting paininjection followed by severe, unremitting pain
accompanied by edema, numbness, discoloration, cyanosis, accompanied by edema, numbness, discoloration, cyanosis, mottlingmottling
STEVE HENAO MDSTEVE HENAO MD
QUESTIONS?QUESTIONS?
INTERESTING STORIES?INTERESTING STORIES?
VASCULAR VASCULAR EMERGENCIESEMERGENCIESSTEVE HENAO MDSTEVE HENAO MDVascular Surgery & Vascular Interventional Vascular Surgery & Vascular Interventional RadiologyRadiology
New Mexico Heart InstituteNew Mexico Heart Institute