02/01/2014

Vascular InjuriesMohammad Shihata

Objectives

✤ Principles of trauma management

✤ Vascular zones of the body

✤ Mechanisms of vascular trauma

✤ Recognition of vascular injuries

✤ Management of Vascular injuries

My ATLS App for smart phones and tablets

A, B, C, D, E

Primary survey–A Airway maintenance with cervical spine protection–B Breathing and ventilation–C Circulation with hemorrhage control–D Disability : Neurological status–E Exposure/Environmental control : completelyundress the patient,but prevent hypothermia

Resuscitation

✤ Control Bleeding

✤ Protect and maintain airway

✤ Two large bore IVs for rapid infusion

Secondary survey

Secondary survey does not begin untilthe primary survey (ABCDEs) iscompleted, resuscitative efforts arewell established, and the patient isdemonstrating normalization of vitalfunctions.

Secondary Survey

– Total patient evaluation• history : AMPLE• physical examination– Complete neurologic examination– Head and skull– Maxillofacial– Neck– Chest– Abdomen– Perineum/rectum/vagina– Musculoskeletal– Tubes and fingers in every orifice

“He Who wants to be a surgeon, should go to war”

Hippocrates (460 - 377 BC)

Mechanisms of Vascular Injuries

✤ Penetrating Trauma

✤ Blunt Trauma

✤ Blast injuries

✤ Iatrogenic Injuries

Ask yourself

Is this blunt or penetrating injury ?Is this blunt or penetrating injury ?

Is this Arterial or Venous injury ?Is this Arterial or Venous injury ?

Should I take the patient to the operating room or do further Should I take the patient to the operating room or do further investigations?investigations?

Arterial injuries

✤ Low pressure

✤ Dark blood

✤ Non-expanding hematoma

Venous Injuries

Upper Extremity

Lower Extremity

Neck Vessels

Thoracic Aorta

Aortic Arch Tear

Aortic Arch Transection

✤ Common in deceleration ( blunt ) type injuries

✤ Most common site is the ligamentum attachment ( isthmus)

✤ Free rupture is incompatible with life

✤ Contained rupture is associated with increased risk of free rupture

✤ Usually associated with other life threatening injuries

Principles of Vascular Repairs

✤ Know your anatomy ( Course, Feeding vessel, Run-off)

✤ Adequate Exposure

✤ Proximal and distal control

✤ Tension free repair

✤ Adjuncts (intra op tPA, Imaging, .....)

✤ Assess the need for fasciotomy

Options for peripheral vascular repair

✤ Primary Repair

✤ Patch Angioplasty

✤ Endovascular treatment

No Transection

Complete Transection

✤ Primary end to end anastomosis

✤ Interposition graft

✤ Bypass

Patch angioplasty

End to End anastomosis

Complications of Vascular Injuries

✤ Life threatening bleeding

✤ End organ ischemia

✤ Associated injuries

✤ Sensory / Motor Loss

✤ AV fistula

✤ Pseudoaneurysm

Thank You