9. Vascular injuries

Question 1

Describe: Vascular injuries (2)

Answer 1

• Vascular injuries are classified as blunt and penetrating, can occur anywhere in the body, and may be limb- or life-threatening if not identified and managed promptly.
• Most patients with major vessel trauma die before arrival to hospital.

Question 2

Name examples: Blunt trauma (2)

Answer 2

• Contusion
• Acceleration/deceleration injury

Question 3

Name examples: Penetrating trauma (2)

Answer 3

• Stab wound
• Gunshot wound

Question 4

Name examples: Compartment Syndrome (5)

Answer 4

• Crush or long bone injury
• Unrecognized/uncontrolled bleeding
• Ischemic reperfusion injury
• Burns
• Binding casts/dressings

Question 5

Compare: Occlusive Injury vs Hemorrhagic Injury

Answer 5

Question 6

Describe: Compartment syndrome (4)

Answer 6

• pain out of proportion to physical exam
• pain on passive stretch or active flexion of the compartment
• parasthesia in the distal peripheral nerves that cross the compartment
• Compartment pressure > 30 mm Hg of patient’s Diastolic Blood Pressure (DBP) leading to vascular occlusion and tissue ischemia.

Question 7

Describe: API (2)

Answer 7

• Arterial Pressure Index
• ratio of SBP distal to arterial injury site to SBP measured in contralateral uninjured limb, normally ≥0.9, not to be confused with Ankle Brachial Index (ABI).

Question 8

Name sx Arterial Insufficiency (6)

Answer 8

6Ps

In order of severity:

• Pain
• Pallor
• Polar (cold)
• Pulseless
• Paresthesias
• Paralysis

Question 9

Name investigations: Vascular injuries (4)

Answer 9

As clinically indicated

• Arterial Pressure Index (API)
• Ankle Brachial Index (ABI)
• CT Angiogram (CTA)
• Ultrasound (U/S)

Question 10

Name dx: Vascular injuries (5)

Answer 10

• Aay be subclinical on initial assessment. High-risk patients require serial exams.
• Arterial injuries can be occlusive or hemorrhagic.
• Injuries that involve arterial transection have both occlusive and hemorrhagic features.
• The two most common vascular injuries are arterial trauma and compartment syndrome.
• Pulsatile bleeding/hematoma or any of the six Ps of arterial insufficiency carries a > 90% incidence of arterial injury, and 50% have an associated nerve injury.

Question 11

Name management: Vascular injuries (3)

Answer 11

• It is vital to quickly identify and treat vascular injuries as they carry significant short- and long-term consequences (hemorrhagic shock, distal limb ischemia, thromboembolic events, true and false aneurysms, and fistulae formation)
• Arterial injuries should be initially managed with direct pressure, avoiding tourniquets and the use of clamps.
• Vascular surgery should become involved early in the management of a suspected arterial injury, or patient should be transported to a center with access to a vas- cular surgeon.

Question 12

Name Vascular Injury Dx Tests (7)

Answer 12

• CBC, if hemorrhage
• Plain XR (fractures, Foreign Body)
• U/S ± duplex
• Handheld Doppler
• Arterial Pressure Index (API)
• Angiography
• Surgical exploration

Question 14

Describe: Initial assessment for vascular injury (Figure)

Answer 14

Question 15

Name: Risks of Tourniqets and Clamps (2)

Answer 15

• Vessel clamping can → crushing of nearby nerves
• Tourniquets →↑ compartment pressure; ↑ risk of venous thrombi 2° to stasis

Question 16

Describe: Warm ischemia (2)

Answer 16

Six hours after sustaining a vascular injury, 10% of patients will have irreversible neuromuscular injury. After 12 h, the incidence is 90%.