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Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Slide 2: VASCULAR TRAUMAS Slide 3: VASCULAR TRAUMAS AND THEIR MANAGEMENT BY Prof. Dr. AHMED ELAMRAWY Professor of Vascular Surgery Faculty of Medicine - Alexandria University Slide 4: Trauma is the leading cause of death during the first three decades of life. Vascular wounds cause many of these deaths and often result in severe disability. Major vascular injuries are encountered in civilian practice, stab wound and gunshot wounds. Slide 5: Biomechanics of injury Classically, injury mechanisms are divided into penetrating or blunt type. Following blunt trauma, tissue injury is produced by local compression or rapid deceleration. In penetrating trauma, the injury is produced by crushing and separation of tissues along the path of the penetrating object. Slide 6: Iatrogenic damage is an abnormal state that occurs in patients as a result of inadvertent or erroneous treatment by medical staffs. Vascular iatrogenic injuries are fairly rare though their incidence is steadily increasing. Currently iatrogenic vascular trauma is responsible for 5% to 75% of all vascular injuries, an incidence that varies according to type of practice and referral bias. Slide 7: Penetrating injuries produce vascular wounds are usually caused by stabbing, or by low velocity bullets. High velocity bullet or metal fragment produces great tissue damage in military wounds. Slide 8: Blunt trauma as road accidents or fall from height are a major cause of closed vascular trauma and often the victims have a multiple injuries. Iatrogenic arterial injuries are increasing as arterial catheterization or during surgery. Slide 9: Injury severity is proportional to the amount of kinetic energy (KE) transferred to the tissues, which is a function of mass (M) and velocity (V): KE = M × V2/2 This is valid for both blunt and penetrating mechanisms. RISK FACTORS OF IVT: : RISK FACTORS OF IVT: Factors related to the patient: Age, sex, obesity, systemic diseases, Factors related to the procedure: Duration, approach, type of the procedure, anticoagulation & thrombolytics Slide 11: The most common form of presentation of extremity arterial injury is acute ischemia. This occurs most commonly after stab wounds, low-velocity gunshot wounds, and blunt trauma associated with fractures and dislocations. Classically, signs and symptoms of arterial injury are divided into HARD and SOFT categories. SIGNS OF VASCULAR INJURY : SIGNS OF VASCULAR INJURY ¨Hard signs¨ Arterial bleeding Ongoing hemorrhage with shock Absent distal pulses Limb ischemia Expanding or pulsatile hematoma Bruit or thrill over area of injury ¨Soft signs¨ History of serious bleeding now stopped Small, non expanding hematoma Injury to anatomically related nerve Diminished distal pulses Anatomic proximity of wound to a major vessel (< 1cm distance to course of the vessel) Mechanisms of injury : Mechanisms of injury COMPLICATIONS OF IVT: : COMPLICATIONS OF IVT: Bleeding. Pseudoaneurysm. Arteriovenous fistulae. Dissection. Acute vessel thrombosis or occlusion. Peripheral embolization. Arterial perforation. Miscellaneous: Neurologic, arrhythmias, vasovagal INVESTIGATIONS OF IVT: : INVESTIGATIONS OF IVT: Lab studies: Baseline blood work should consists of a CBC with platelet count, electrolytes, blood urea, …etc. Typing and cross matching of packed red blood cells. Prothrombin time and activated partial thromboplastin time. Imaging studies: Duplex ultrasound studies. Angiography CT scanning MRI Other tests: Ankle-brachial index; ABI cannot localize the site of injury. Assessing for a Doppler signal in peripheral vessels. Slide 16: ARTERIOGRAPHY For patients with overt signs of arterial injuries, immediate surgical exploration is preferred. In most instances, when arteriography is required, an intraoperative arteriogram is sufficient to identify the location and extent of injury and to guide the surgical repair. Slide 17: It is now widely accepted that selective rather than routine arteriography is appropriate for patients who may have an occult extremity arterial injury. Slide 18: COLOR-FLOW DUPLEX (CFD) ULTRASONOGRAPHY has been suggested as a substitute for or complement to arteriography. It is noninvasive and painless. It is portable and can easily be brought to the patient’s bed side or the emergency department or operating room. Repeated and follow up examinations are easily performed without morbidity and are relatively inexpensive. Slide 19: MAGNETIC RESONANCE ANGIOGRAPHY (MRA) being noninvasive, preventing the need for contrast agents. Unfortunately, MRA is not easily accessible in most hospitals, and the presence of metallic orthopedic instrumentation limits widespread usage for trauma patient. Slide 20: TREATMENT: Conservative Strategies: Surgical management: Peripheral ischemia: Pseudoaneurysms or pulsating hematoma: Arteriovenous fistulas: Retroperitoneal hematoma: Sympathectomies: Amputation: Slide 21: Time lag (or time accident treatment) Slide 22: Duplex ultrasound showing pseudoaneurysm. Duplex ultrasound showing AVF between the femoral artery and vein TREATMENT OF ARTERIAL INJURIES The most important factors in successful management of iatrogenic vascular injuries are early recognition and prompt correction. : TREATMENT OF ARTERIAL INJURIES The most important factors in successful management of iatrogenic vascular injuries are early recognition and prompt correction. Delay in repair of a vascular injury was a factor in 75% of permanent functional disabilities and, or amputations. (Lazarides MK, Tsoupanos SS, Doundoulakis NJ, et al. Incidence and pattern of iatrogenic arterial injuries: a decade’s experience. J Cardiovasc Surg (Torino) 1998; 39: 281-5.) Slide 35: Nonoperative management The management of minimal, nonocclusive, clinically asymptomatic arterial injuries detected by arteriography remains controversial. Some surgeons continue to insist that all detected arterial injuries should be repaired. Slide 36: Endovascular management Transcatheter embolization with coils or balloons can be used to manage selected arterial injuries, such as low-flow arteriovenous fistulae, false aneurysms, and active bleeding from noncritical arteries, particularly in remote anatomic sites. Coils (made from stainless steel, wool or Dacron tufted) are particularly useful for occluding bleeding vessels and arteriovenous fistulae. Slide 37: Another endovascular approach to extremity injuries uses stent-graft technology. By combining a fixation device such as a stent with a graft, endoluminal repair of false aneurysms or large arteriovenous fistulae is possible. Slide 38: Operative management The operative management of a peripheral arterial injury requires preparation and draping of the entire injured extremity. In most instances, extremity incisions are placed longitudinally, directly over the injured vessel. Proximal and distal arterial control obtained prior to exposure of the injury. Slide 39: Once control is established, injured vessels are débrided to macroscopically normal arterial wall. Fogarty catheters should be passed gently, both proximal and distal to the arterial injury, to remove intraluminal thrombus. Slide 40: Both proximal and distal arterial Lumina are flushed with heparinized saline solution. Systemic heparinization, particularly for popliteal artery injuries, is a helpful adjunct to prevent thrombosis or thrombus propagation when systemic anticoagulation is not contra-indicated. Slide 41: The type of repair is dictated by the extent of arterial damage. Repair of injured vessels can be accomplished by lateral suture patch angioplasty, end-to-end anastomosis, or interposition graft. Extra-anatomic bypass grafts are useful in patients with associated extensive soft tissue injury or sepsis. Slide 42: Open surgical repair remains the gold standard of therapy by which all treatment modalities are compared. Slide 43: To remember Slide 44: Acute ischaemia is the most common presentation of peripheral arterial injuries. We must suspect arterial injury in a trauma at or nearby the coarse of a main artery. Early recognition of ischaemia and early intervention in the first 6 hours is mandatory. In clinically obvious arterial injury, immediate surgical exploration without further diagnostic testing is preferred. Slide 45: Fasciotomy when indicated should be done early and adequate. Immobilization of the associated fracture should be done. In a limb with massive orthopedic soft tissue and nerve injuries, primary amputation should be considered rather than complex reconstruction. Slide 46: Thank You You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
vascular trauma alexdoctor Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 2876 Category: Education License: All Rights Reserved Like it (8) Dislike it (0) Added: July 21, 2008 This Presentation is Public Favorites: 2 Presentation Description vascular trauma Comments Posting comment... By: mahmood123 (15 month(s) ago) This is a very good perssentation can I get a copy please mahmoodxr@yahoo.com Saving..... Post Reply Close Saving..... Edit Comment Close By: najfaca (16 month(s) ago) fdgggg Saving..... Post Reply Close Saving..... Edit Comment Close By: najfaca (16 month(s) ago) ovo je fantasticno Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Slide 2: VASCULAR TRAUMAS Slide 3: VASCULAR TRAUMAS AND THEIR MANAGEMENT BY Prof. Dr. AHMED ELAMRAWY Professor of Vascular Surgery Faculty of Medicine - Alexandria University Slide 4: Trauma is the leading cause of death during the first three decades of life. Vascular wounds cause many of these deaths and often result in severe disability. Major vascular injuries are encountered in civilian practice, stab wound and gunshot wounds. Slide 5: Biomechanics of injury Classically, injury mechanisms are divided into penetrating or blunt type. Following blunt trauma, tissue injury is produced by local compression or rapid deceleration. In penetrating trauma, the injury is produced by crushing and separation of tissues along the path of the penetrating object. Slide 6: Iatrogenic damage is an abnormal state that occurs in patients as a result of inadvertent or erroneous treatment by medical staffs. Vascular iatrogenic injuries are fairly rare though their incidence is steadily increasing. Currently iatrogenic vascular trauma is responsible for 5% to 75% of all vascular injuries, an incidence that varies according to type of practice and referral bias. Slide 7: Penetrating injuries produce vascular wounds are usually caused by stabbing, or by low velocity bullets. High velocity bullet or metal fragment produces great tissue damage in military wounds. Slide 8: Blunt trauma as road accidents or fall from height are a major cause of closed vascular trauma and often the victims have a multiple injuries. Iatrogenic arterial injuries are increasing as arterial catheterization or during surgery. Slide 9: Injury severity is proportional to the amount of kinetic energy (KE) transferred to the tissues, which is a function of mass (M) and velocity (V): KE = M × V2/2 This is valid for both blunt and penetrating mechanisms. RISK FACTORS OF IVT: : RISK FACTORS OF IVT: Factors related to the patient: Age, sex, obesity, systemic diseases, Factors related to the procedure: Duration, approach, type of the procedure, anticoagulation & thrombolytics Slide 11: The most common form of presentation of extremity arterial injury is acute ischemia. This occurs most commonly after stab wounds, low-velocity gunshot wounds, and blunt trauma associated with fractures and dislocations. Classically, signs and symptoms of arterial injury are divided into HARD and SOFT categories. SIGNS OF VASCULAR INJURY : SIGNS OF VASCULAR INJURY ¨Hard signs¨ Arterial bleeding Ongoing hemorrhage with shock Absent distal pulses Limb ischemia Expanding or pulsatile hematoma Bruit or thrill over area of injury ¨Soft signs¨ History of serious bleeding now stopped Small, non expanding hematoma Injury to anatomically related nerve Diminished distal pulses Anatomic proximity of wound to a major vessel (< 1cm distance to course of the vessel) Mechanisms of injury : Mechanisms of injury COMPLICATIONS OF IVT: : COMPLICATIONS OF IVT: Bleeding. Pseudoaneurysm. Arteriovenous fistulae. Dissection. Acute vessel thrombosis or occlusion. Peripheral embolization. Arterial perforation. Miscellaneous: Neurologic, arrhythmias, vasovagal INVESTIGATIONS OF IVT: : INVESTIGATIONS OF IVT: Lab studies: Baseline blood work should consists of a CBC with platelet count, electrolytes, blood urea, …etc. Typing and cross matching of packed red blood cells. Prothrombin time and activated partial thromboplastin time. Imaging studies: Duplex ultrasound studies. Angiography CT scanning MRI Other tests: Ankle-brachial index; ABI cannot localize the site of injury. Assessing for a Doppler signal in peripheral vessels. Slide 16: ARTERIOGRAPHY For patients with overt signs of arterial injuries, immediate surgical exploration is preferred. In most instances, when arteriography is required, an intraoperative arteriogram is sufficient to identify the location and extent of injury and to guide the surgical repair. Slide 17: It is now widely accepted that selective rather than routine arteriography is appropriate for patients who may have an occult extremity arterial injury. Slide 18: COLOR-FLOW DUPLEX (CFD) ULTRASONOGRAPHY has been suggested as a substitute for or complement to arteriography. It is noninvasive and painless. It is portable and can easily be brought to the patient’s bed side or the emergency department or operating room. Repeated and follow up examinations are easily performed without morbidity and are relatively inexpensive. Slide 19: MAGNETIC RESONANCE ANGIOGRAPHY (MRA) being noninvasive, preventing the need for contrast agents. Unfortunately, MRA is not easily accessible in most hospitals, and the presence of metallic orthopedic instrumentation limits widespread usage for trauma patient. Slide 20: TREATMENT: Conservative Strategies: Surgical management: Peripheral ischemia: Pseudoaneurysms or pulsating hematoma: Arteriovenous fistulas: Retroperitoneal hematoma: Sympathectomies: Amputation: Slide 21: Time lag (or time accident treatment) Slide 22: Duplex ultrasound showing pseudoaneurysm. Duplex ultrasound showing AVF between the femoral artery and vein TREATMENT OF ARTERIAL INJURIES The most important factors in successful management of iatrogenic vascular injuries are early recognition and prompt correction. : TREATMENT OF ARTERIAL INJURIES The most important factors in successful management of iatrogenic vascular injuries are early recognition and prompt correction. Delay in repair of a vascular injury was a factor in 75% of permanent functional disabilities and, or amputations. (Lazarides MK, Tsoupanos SS, Doundoulakis NJ, et al. Incidence and pattern of iatrogenic arterial injuries: a decade’s experience. J Cardiovasc Surg (Torino) 1998; 39: 281-5.) Slide 35: Nonoperative management The management of minimal, nonocclusive, clinically asymptomatic arterial injuries detected by arteriography remains controversial. Some surgeons continue to insist that all detected arterial injuries should be repaired. Slide 36: Endovascular management Transcatheter embolization with coils or balloons can be used to manage selected arterial injuries, such as low-flow arteriovenous fistulae, false aneurysms, and active bleeding from noncritical arteries, particularly in remote anatomic sites. Coils (made from stainless steel, wool or Dacron tufted) are particularly useful for occluding bleeding vessels and arteriovenous fistulae. Slide 37: Another endovascular approach to extremity injuries uses stent-graft technology. By combining a fixation device such as a stent with a graft, endoluminal repair of false aneurysms or large arteriovenous fistulae is possible. Slide 38: Operative management The operative management of a peripheral arterial injury requires preparation and draping of the entire injured extremity. In most instances, extremity incisions are placed longitudinally, directly over the injured vessel. Proximal and distal arterial control obtained prior to exposure of the injury. Slide 39: Once control is established, injured vessels are débrided to macroscopically normal arterial wall. Fogarty catheters should be passed gently, both proximal and distal to the arterial injury, to remove intraluminal thrombus. Slide 40: Both proximal and distal arterial Lumina are flushed with heparinized saline solution. Systemic heparinization, particularly for popliteal artery injuries, is a helpful adjunct to prevent thrombosis or thrombus propagation when systemic anticoagulation is not contra-indicated. Slide 41: The type of repair is dictated by the extent of arterial damage. Repair of injured vessels can be accomplished by lateral suture patch angioplasty, end-to-end anastomosis, or interposition graft. Extra-anatomic bypass grafts are useful in patients with associated extensive soft tissue injury or sepsis. Slide 42: Open surgical repair remains the gold standard of therapy by which all treatment modalities are compared. Slide 43: To remember Slide 44: Acute ischaemia is the most common presentation of peripheral arterial injuries. We must suspect arterial injury in a trauma at or nearby the coarse of a main artery. Early recognition of ischaemia and early intervention in the first 6 hours is mandatory. In clinically obvious arterial injury, immediate surgical exploration without further diagnostic testing is preferred. Slide 45: Fasciotomy when indicated should be done early and adequate. Immobilization of the associated fracture should be done. In a limb with massive orthopedic soft tissue and nerve injuries, primary amputation should be considered rather than complex reconstruction. Slide 46: Thank You