Arterial.3. Arterial injuries Flashcards
CAUSES of arterial injuries
- Open
* Closed
Open CAUSES of arterial injuries
- Penetrating injury e.g. stabs, bullets
2. Following arterial cannulation.
Closed CAUSES of arterial injuries
- Plaster or tourniquet compression.
- Fracture or dislocation such as :
* Supracondylar fracture of humerus & brachial artery-
* Supracondylar fracture of femur & popliteal artery - Blunt injuries.
TYPES of arterial injuries
A. Arterial injury without division :
B. Arterial injury with division :
Pathogenesis of Arterial injury without division in TYPES of arterial injuries
- Arterial spasm
2. Arterial contusion
Etiology of Arterial spasm in Pathogenesis of Arterial injury without division
Occurs as a result :
- Irritation e.g. blunt trauma,
- Tourniquets.
- Passage of high velocity missile near vessel (“ near miss”).
Pathogenesis of Arterial injury with division in TYPES of arterial injuries
- Complete division
2. Partial division
pathogenesis of Complete division in Pathogenesis of Arterial injury with division in TYPES of arterial injuries
Both ends bleed profusely but soon bleeding decreases because the intima curls inside the lumen while the media contracts & the divided stumps retracts
the reason why bleeding decreases soon in pathogenesis of Complete division in Pathogenesis of Arterial injury with division
because the intima curls inside the lumen while the media contracts & the divided stumps retracts
pathogenesis of Partial division in Pathogenesis of Arterial injury with division in TYPES of arterial injuries
- The contraction & retraction of the vessel wall cause the tear in the vessel wall to gap.
- The artery will continue to bleed profusely either externally or internally producing a pulsating haematoma
the reason why profuse bleeding occurs in pathogenesis of Partial division in Pathogenesis of Arterial injury with division in TYPES of arterial injuries
- as The contraction & retraction of the vessel wall cause the tear in the vessel wall to gap.
- The artery will continue to bleed profusely either externally or internally producing a pulsating haematoma
COMPLICATIONS of arterial injuries
- Haemorrhage.: Primary, secondary, or reactionary.
- Ischemia
- Aneurysm formation : Arterial or arterio-venous.
CLINICAL PICTURE of arterial injuries
- General examination
* Local examination
General examination in CLINICAL PICTURE of arterial injuries
- Vital signs for evaluation of the magnitude of blood loss.
* To look for other injuries.
Local examination in CLINICAL PICTURE of arterial injuries
A. Hard signs
B. Soft signs
Hard signs in Local examination in CLINICAL PICTURE of arterial injuries
- Significance
* List
Significance of Hard signs in Local examination in CLINICAL PICTURE of arterial injuries
These are sure signs of arterial injury
List of Hard signs in Local examination in CLINICAL PICTURE of arterial injuries
- External arterial bleeding.
- Loss of distal pulses.
3- Any of the classic manifestations of acute ischemia (6P).
- Pulsating or expanding haematoma.
Soft signs in Local examination in CLINICAL PICTURE of arterial injuries
- Significance
* List
Significance of Soft signs in Local examination in CLINICAL PICTURE of arterial injuries
These are less specific (equivocal) signs.
List of Soft signs in Local examination in CLINICAL PICTURE of arterial injuries
- Small or moderate sized haematoma that is not pulsating and not expanding.
- Proximity of penetrating wound to a major vascular structure.
- Adjacent nerve injury: producing neurological deficit.
INVESTIGATIONS of a case with arterial injury
a. In patients with hard signs
Immediate surgical exploration is indicated without any diagnostic studies as any delay in treatment is dangerous
b.In patients with soft signs: urgent investigations are needed.
urgent investigations In patients with soft signs in INVESTIGATIONS of a case with arterial injury
- Plain X-ray :
- Arteriography : most accurate
- Duplex scan
The reason why plain X-ray is done in urgent investigations In patients with soft signs in INVESTIGATIONS of a case with arterial injury
to detect foreign bodies or fractures.
investigations of a case with hard signs of arterial injury
Immediate surgical exploration is indicated without any diagnostic studies as any delay in treatment is dangerous
TREATMENT of arterial injury
I. Immediate Management
II. Definitive Management
III. Distal Fasciotomy
- If there is a bony fracture, it must be fixed first
Immediate Management in TREATMENT of arterial injury
- Resuscitation by blood and IV fluids.
- Heparinization
- Prophylactic antibiotics should be given early
indication of Heparinization in Immediate Management in TREATMENT of arterial injury
only in patients with isolated vascular injury presenting with ischemia
the reason why Prophylactic antibiotics should be given early in the Immediate Management of a case with arterial injury
as infection may cause secondary hemorrhage
Definitive Management in TREATMENT of arterial injury
Immediate Exploration & Repair of :
A. Complete Arterial Division :
B. Partial Arterial Division :
C. Contusion
D. Spasm
Immediate Exploration & Repair of Complete Arterial Division in Definitive Management in TREATMENT of arterial injury
- Direct end to end anastomosis. If there is no gap.
- Arterial graft:
- Ligation of both ends.Only for small unnamed arteries.
The reason why repair of Complete Arterial Division is done in oblique line sutures in Immediate Exploration & Repair of Complete Arterial Division in Definitive Management in TREATMENT of arterial injury
to avoid annular stricture
Arterial graft in Immediate Exploration & Repair of Complete Arterial Division in Definitive Management in TREATMENT of arterial injury
- Indication
* Types of graft
Indication of Arterial graft in Immediate Exploration & Repair of Complete Arterial Division in Definitive Management in TREATMENT of arterial injury
if there is gap
Types of graft in Arterial graft in Immediate Exploration & Repair of Complete Arterial Division in Definitive Management in TREATMENT of arterial injury
- Autogenous reversed saphenous vein graft. for small arteries
- Synthetic grafts of Dacron or Teflon for Medium sized & large arteries
Immediate Exploration & Repair of Partial Arterial Division in Definitive Management in TREATMENT of arterial injury
in case of :
- Longitudinal tear of Large artery
- Longitudinal tear of Medium sized artery
- Transverse tear and involves < 1/2 circumference
- Transverse tear and involves > 1/2 circumference
Immediate Exploration & Repair of Partial Arterial Division, in Definitive Management in TREATMENT of arterial injury, in case of Longitudinal tear of Large artery
do Direct suture.
Immediate Exploration & Repair of Partial Arterial Division, in Definitive Management in TREATMENT of arterial injury, in case of Longitudinal tear of Medium sized artery
do Vein patch graft
Immediate Exploration & Repair of Partial Arterial Division, in Definitive Management in TREATMENT of arterial injury, in case of Transverse tear and involves < 1/2 circumference
Direct anastomosis.
Immediate Exploration & Repair of Partial Arterial Division, in Definitive Management in TREATMENT of arterial injury, in case of Transverse tear and involves > 1/2 circumference
Turn it into complete
Immediate Exploration & Repair of Contusion in Definitive Management in TREATMENT of arterial injury
Excision of the contused part and grafting.
Immediate Exploration & Repair of Spasm in Definitive Management in TREATMENT of arterial injury
1- Local application of papaverine or novocaine.
- Proximal intra-arterial injection of heparinized isotonic saline.
- If the spasm still persists, excision of the spastic segment with a saphenous vein graft is performed.
Indications of Distal Fasciotomy in Definitive Management in TREATMENT of arterial injury
It is a must in the following situations
- In late cases (> 6 hours).
- In presence of muscle edema
