Chapter 180 - Epidemiology and natural history of vascular trauma

Question 1

Rank in the causes of mortality

Answer 1

3 #1 in age 1-46 #1 preventable mortality in wartime = hemorrhage

Question 2

WHO definition of epidemiology

Answer 2

Study of the distribution and determinants of health-related states or events in specified population Goal: to control health problems

Question 3

Galen 2nd century in vascular trauma

Answer 3

Vessel ligation techniques

Question 4

Ambroise Pare 16th century

Answer 4

French military surgeon: vessel ligation in trauma

Question 5

Alexis Carrell 1902 french surgeon

Answer 5

Arterial anastamosis; won nobel prize 1912

Question 6

WWII incidence of vascular injury

Answer 6

1% Attempted revasc 5% Amputation rate 49%

Question 7

Korea war incidence of vascular injury

Answer 7

2% Attempted 88% Amputation rate 13%

Question 8

Colonel Carl Hughes

Answer 8

Demonstrated decrease amputation rates from WWII to Korea Faster evacuation Venous repairs

Question 9

Improvements brought upon by Vietnam war

Answer 9

Registry existence Venous repair was emphasized Published by Rich et al

Question 10

Global war on terror brought improvements

Answer 10

Tournequet use on field Tactical combat casualty care guidelines More extremity less truncal injuries

Question 11

Different wars and their researchers

Answer 11

WWI - Makins WWII - Debakey Korea - Hughes Vietnam - Riel, McNamara GWOT - Dua, White

Question 12

Vascular trauma categories

Answer 12

Tier 1: periphery, extremity –> distal to axillary or CFA/V Tier 2: proximal groin or axillary Tier 3: intracavitary wounds

Question 13

Neck trauma incidence

Answer 13

0.2% incidence: 41% penetrating 59% blunt

Question 14

Carotid artery trauma location

Answer 14

37% internal 20% CCA 10% mixed 33% unknown

Question 15

Blunt trauma mechanism of carotid artery

Answer 15

1) stretch from hyperflexion, extension, rotation at base of internal carotid 2) high velocity MVC 79% with 50% severe brain injury

Question 16

Rate of bilateral carotid or associated vertebral injury

Answer 16

20-50%

Question 17

Mortality after blunt carotid injury

Answer 17

50%

Question 18

Neurologic deficit in survivors of carotid injury

Answer 18

16%

Question 19

Vertebral injury incidence

Answer 19

1-7% of penetrating neck 1% of blunt neck trauma

Question 20

Vertebral injury mortality

Answer 20

10-20% if isolated 50% if also carotid 78% if associated spine #

Question 21

Vertebral injury association

Answer 21

40% of spine fracture has vertebral injury posterior stroke 24%

Question 22

Non-compressible torso hemorrhage treatment principles

Answer 22

1) minimize delay in transfer from ER to OR 2) permissive hypotension until VSx control obtained 3) balanced/hemostatic resuscitation with early use of blood 4) procoag adjunct (TXA) 5) damage control surgery with intravascular shunt

Question 23

Thoracic Aortic injury causes

Answer 23

90% penetrating

Question 24

Most common region of penetrating aortic injury

Answer 24

28% thoracic

Question 25

Blunt trauma in thoracic aorta most common location

Answer 25

98% at ligamentum arteriosum or distal to origin of LSCA

Question 26

Blund TAI grades

Answer 26

Gr 1: intimal tear Gr 2: intimal flap/IMH Gr 3: pseudoaneurysm Gr 4: rupture

Question 27

Ascending aortic blunt injury causes

Answer 27

1) sudden displacement of intact sternum 2) displace # or dislocated sternum 3) torsion tear of heart apex (98% die of tamponade)

Question 28

Fabian 1997 AAST-1 study treatment technique and outcome for thoracic aortic injury

Answer 28

35% clamp and sew 65% bypass Mortality 31% Paraplegia 9%

Question 29

Modern practice for thoracic aortic injury and outcome

Answer 29

TEVAR 76% Mortality 8.6% Aortic mortality 2.5% Paraplegia 0.5%

Question 30

Outcome following injury to great vessels

Answer 30

90% death in 30 min

Question 31

Incidence of great vessel injury

Answer 31

5% gun 2% stab \<1% blunt

Question 32

Great vessel injury patency of repair

Answer 32

\>90%

Question 33

Great vessel injury chance to be multivessel

Answer 33

65%

Question 34

Arm ischemia rate after LSCA coverage

Answer 34

4-5%

Question 35

Upper extremity injury rate

Answer 35

1.7% 23% involve axillary and subclavian 1/3 involve venous injury

Question 36

Upper extremity blunt injury key points

Answer 36

1) shear force 2) clavicle # 3) concomitant nerve injury 40-100% 4) amputation 3-15% 5) Mortality 25%

Question 37

Abdominal injury incidence and types

Answer 37

34% Penetrating 89% Multivessel 36% Venous 53% Arterial 47% Both 53%

Question 38

Abdominal injury mortality following number of vessels injured

Answer 38

1 vessel: 45% 2 vessels: 60% 3 vessels: 73%

Question 39

Strongest independent predictor of death following abdominal injury

Answer 39

Hypotension 25%

Question 40

Mortality following types of vessel injured in abdomen

Answer 40

IVC: 52% Aorta: 35% SMA: 45% Portal/hepatic venous: 22%

Question 41

Zones of abdominal injury

Answer 41

Zone 1: central (aorta, ivc) Zone 2: lateral (Renal) (penetrating 50%) Zone 3: iliac (Blunt 70%) Zone 4: hepatoportal

Question 42

Morbidity and mortality with retroperitoneal hematoma

Answer 42

60% morbidity 13-40% mortality

Question 43

Zone 1 blunt aortic injury cause

Answer 43

56% death due to seatbelt most common at junction of IMA and aorta or aortic bifurcation

Question 44

Signs of Zone 1 blunt aortic injury

Answer 44

1) bruising 2) arterial insufficiency 3) acute abdomen 4) weakness

Question 45

Mortality after zone 1 blunt aortic injury

Answer 45

20-40% 83% if \> 65 years old

Question 46

Zone 1 penetrating aortic injury causes

Answer 46

Gun 78%

Question 47

Mortality after zone 1 penetrating aortic injury

Answer 47

33-81%

Question 48

Rate of zone 1 penetrating aortic injury by location in aorta

Answer 48

Infrarenal 45% Suprarenal 37% Subdiaphragmatic 18

Question 49

San Diego study for penetrating aortic injury

Answer 49

Straight to OR and bypass ER Reduced mortality from 78% to 40%

Question 50

Zone 1 IVC injury incidence

Answer 50

6.7% of all penetrating injuries 3.4% of all blunt injuries Most common in infrarenal IVC

Question 51

Associated injury with IVC injury

Answer 51

Duodenum 31% Liver 29% Pancreas 26%

Question 52

Mortality after IVC injury

Answer 52

70% 78% if combined venous injury

Question 53

Celiac/mesenteric vessel injury incidence and mortality

Answer 53

Rare Usually have associated other injuries Mortality 20-40%

Question 54

Zone 2 renal injury causes

Answer 54

50/50 blunt/penetrating Associated injury 77%

Question 55

Mortality following zone 2 renal injury

Answer 55

30% nephrectomy needed in 51%

Question 56

Zone 3 iliac vessels injury incidence

Answer 56

\< 1% 56% will have multiple injuries

Question 57

Mortality after Zone 3 iliac injury

Answer 57

28-49%

Question 58

Causes of zone 3 iliac injuries

Answer 58

Gun 86-95%

Question 59

Location of iliac injury Zone 3

Answer 59

CIA + EIA 68% IIA 32%

Question 60

Zone 4 hepatoportal vessels mortality

Answer 60

92-100%

Question 61

Extremity trauma incidence

Answer 61

1-2% LE 66% UE 34%

Question 62

Mortality and limb loss after extremity trauma

Answer 62

10% LE worse

Question 63

Natural History of Various Types of Vascular Injuries and Potential Future Complications

Answer 63