Vascular injury •(1) Blunt : post M.V.A , fracture , dislocation •(2) Penetrating : •( stab wound , gunshot , fall , explosives ) •(3) Iatrogenic ( angiography , cardiac cath, central line) 5-10% incidence •(4) Self induced ( drug abuse ) Males 80% ( 20-40 y ) High Risk Areas for Peripheral Vascular injury •Upper limb : • 1) Axilla • 2) Deltopectoral groove •Lower limb : • 1) Inguinal region • 2) Popliteal fossa نسخ من fhfh fhfh Femoral Triangle vas3 Step Dissection of the Popliteal Fossa Untitled-1vas5 صورة1 Anastomosis around the Knee Physiology of Bleeding §Vasoconstriction , • platelet aggregation §Coagulation intrinsic , extrinsic §Hypotension § § § ( Haemostasis ) Vascular Pathology §Intimal injury §Thrombosis §Transection : Partial , or complete §Bleeding : • false aneurysm ( hematoma) • hemorrhage , exsanguination § § History •Mechanism of trauma ( etiology ) •Time interval •Prior vascular injury or D.V.T •Anticoagulation therapy •Specific vascular symptoms • Pulsatile mass , bleeding , ischemia Examination v vVital signs vVascular examination vArterial pressure index vAnkle / brachial index vAllen index v 3966F532BFD14E9CB57C1098CBD78F91 18281828image_4 Diagnosis •Hard signs of vascular injury post trauma : §Pulsatile bleeding §Visible expanding hematoma §Distal ischemia (5 P’s) §Arterial thrill (( vibration )) §Bruit over artery •Distal normal pulses does not preclude vascular injury § •Hypotension or shock •Neurologic deficit , fracture , dislocation •Stable, nonpulsatile or small hematoma •Proximity of the wound to major vascular structures Diagnosis Soft signs of vascular injury post trauma : Investigation §Blood C.B.C , electrolytes B.U.N , creat. , P.T. , P.T.T §Duplex doppler ultrasound ( soft signs ) §Multidetector helical CT (MDCT) angiography §Angiography ( hard signs ) • • * Renal toxicity avoid by rehydrat.+ alkaliniz. of urine • * Allergy • * Cost , time consuming , expertise • * iatrogenic tauma ( 0.6% ) § 430scan2-294 153430scan1-500 image19 fry10l nic_k201_008 Management §Resuscitation §Reduce displaced fracture , dislocation §Stop hemorrhage : • - Direct pressure • - Avoid tournique except in exanguination • - Avoid clamps § General § Surgical exploration § Indication • Hard signs of vascular injury, • Refractory hypotension, • Obvious limb ischemia Management Specific Vascular Repair §Arterial repair: • (1) direct arterial repair. • (2) arterial patch repair. • (3) interposition graft repair. • (4) bypass repair. § §Venous repair whenever possible • avoid ligation. • Compartment syndrome §Swelling of muscles causing compression of nerves and blood vessels. § §Pathophysiology • prolonged ischemia à tissue hypoxia à anaerobic metabolism à lactic acid accumulation àreperfusionà vasodilatationà transudation Common causes of compartment syndrome • (1) Tibial or forearm fractures. • (2) Ischemic-reperfusion following injury. • (3) Haemorrhage . • (4) Vascular puncture. • (5) Intravenous drug injection, • (6) Casts. • (7) Prolonged limb compression • (8) Crush injuries • (9) Burns نسخ من master_73 1 • 1)Anterior 2) Lateral 3)Superf. Poster. 4)Deep poster. 5) 2 Four major leg compartments Morbidity • Limb loss • (1) When limb perfusion is compromised for more than 6 hours warm ischemia • (2) Extensive musculoskeletal damage. • (3) Open tibial fracture • (4) Compartment syndrome • •Paralysis Post nerve injury •D.V.T post venous injury • • Factors Predicting Risk of Amputation • The MESS score : • (1) Degree of skeletal/soft tissue injury . • (2) Limb ischemia . • (3) Shock . • (4) Patient age . • • MESS = mangled extremity severity score .( Heflet et al ,1990) Mortality • Rare except from : •(1) Exsanguination •(2) Necrotizing myofascial infection •(3) Rhabdomyolysis and Renal failure in untreated acute compartment syndrome Any questions ? Thank you