Chapter 180 - Epidemiology and natural history of vascular trauma Flashcards
Rank in the causes of mortality
3 #1 in age 1-46 #1 preventable mortality in wartime = hemorrhage
WHO definition of epidemiology
Study of the distribution and determinants of health-related states or events in specified population Goal: to control health problems
Galen 2nd century in vascular trauma
Vessel ligation techniques
Ambroise Pare 16th century
French military surgeon: vessel ligation in trauma
Alexis Carrell 1902 french surgeon
Arterial anastamosis; won nobel prize 1912
WWII incidence of vascular injury
1% Attempted revasc 5% Amputation rate 49%
Korea war incidence of vascular injury
2% Attempted 88% Amputation rate 13%
Colonel Carl Hughes
Demonstrated decrease amputation rates from WWII to Korea Faster evacuation Venous repairs
Improvements brought upon by Vietnam war
Registry existence Venous repair was emphasized Published by Rich et al
Global war on terror brought improvements
Tournequet use on field Tactical combat casualty care guidelines More extremity less truncal injuries
Different wars and their researchers
WWI - Makins WWII - Debakey Korea - Hughes Vietnam - Riel, McNamara GWOT - Dua, White
Vascular trauma categories
Tier 1: periphery, extremity –> distal to axillary or CFA/V Tier 2: proximal groin or axillary Tier 3: intracavitary wounds
Neck trauma incidence
0.2% incidence: 41% penetrating 59% blunt
Carotid artery trauma location
37% internal 20% CCA 10% mixed 33% unknown
Blunt trauma mechanism of carotid artery
1) stretch from hyperflexion, extension, rotation at base of internal carotid 2) high velocity MVC 79% with 50% severe brain injury
Rate of bilateral carotid or associated vertebral injury
20-50%
Mortality after blunt carotid injury
50%
Neurologic deficit in survivors of carotid injury
16%
Vertebral injury incidence
1-7% of penetrating neck 1% of blunt neck trauma
Vertebral injury mortality
10-20% if isolated 50% if also carotid 78% if associated spine #
Vertebral injury association
40% of spine fracture has vertebral injury posterior stroke 24%
Non-compressible torso hemorrhage treatment principles
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
Thoracic Aortic injury causes
90% penetrating
Most common region of penetrating aortic injury
28% thoracic
Blunt trauma in thoracic aorta most common location
98% at ligamentum arteriosum or distal to origin of LSCA
Blund TAI grades
Gr 1: intimal tear Gr 2: intimal flap/IMH Gr 3: pseudoaneurysm Gr 4: rupture
Ascending aortic blunt injury causes
1) sudden displacement of intact sternum 2) displace # or dislocated sternum 3) torsion tear of heart apex (98% die of tamponade)
Fabian 1997 AAST-1 study treatment technique and outcome for thoracic aortic injury
35% clamp and sew 65% bypass Mortality 31% Paraplegia 9%
Modern practice for thoracic aortic injury and outcome
TEVAR 76% Mortality 8.6% Aortic mortality 2.5% Paraplegia 0.5%
Outcome following injury to great vessels
90% death in 30 min
Incidence of great vessel injury
5% gun 2% stab <1% blunt
Great vessel injury patency of repair
>90%
Great vessel injury chance to be multivessel
65%
Arm ischemia rate after LSCA coverage
4-5%
Upper extremity injury rate
1.7% 23% involve axillary and subclavian 1/3 involve venous injury
Upper extremity blunt injury key points
1) shear force 2) clavicle # 3) concomitant nerve injury 40-100% 4) amputation 3-15% 5) Mortality 25%
Abdominal injury incidence and types
34% Penetrating 89% Multivessel 36% Venous 53% Arterial 47% Both 53%
Abdominal injury mortality following number of vessels injured
1 vessel: 45% 2 vessels: 60% 3 vessels: 73%
Strongest independent predictor of death following abdominal injury
Hypotension 25%
Mortality following types of vessel injured in abdomen
IVC: 52% Aorta: 35% SMA: 45% Portal/hepatic venous: 22%
Zones of abdominal injury
Zone 1: central (aorta, ivc) Zone 2: lateral (Renal) (penetrating 50%) Zone 3: iliac (Blunt 70%) Zone 4: hepatoportal
Morbidity and mortality with retroperitoneal hematoma
60% morbidity 13-40% mortality
Zone 1 blunt aortic injury cause
56% death due to seatbelt most common at junction of IMA and aorta or aortic bifurcation
Signs of Zone 1 blunt aortic injury
1) bruising 2) arterial insufficiency 3) acute abdomen 4) weakness
Mortality after zone 1 blunt aortic injury
20-40% 83% if > 65 years old
Zone 1 penetrating aortic injury causes
Gun 78%
Mortality after zone 1 penetrating aortic injury
33-81%
Rate of zone 1 penetrating aortic injury by location in aorta
Infrarenal 45% Suprarenal 37% Subdiaphragmatic 18
San Diego study for penetrating aortic injury
Straight to OR and bypass ER Reduced mortality from 78% to 40%
Zone 1 IVC injury incidence
6.7% of all penetrating injuries 3.4% of all blunt injuries Most common in infrarenal IVC
Associated injury with IVC injury
Duodenum 31% Liver 29% Pancreas 26%
Mortality after IVC injury
70% 78% if combined venous injury
Celiac/mesenteric vessel injury incidence and mortality
Rare Usually have associated other injuries Mortality 20-40%
Zone 2 renal injury causes
50/50 blunt/penetrating Associated injury 77%
Mortality following zone 2 renal injury
30% nephrectomy needed in 51%
Zone 3 iliac vessels injury incidence
< 1% 56% will have multiple injuries
Mortality after Zone 3 iliac injury
28-49%
Causes of zone 3 iliac injuries
Gun 86-95%
Location of iliac injury Zone 3
CIA + EIA 68% IIA 32%
Zone 4 hepatoportal vessels mortality
92-100%
Extremity trauma incidence
1-2% LE 66% UE 34%
Mortality and limb loss after extremity trauma
10% LE worse
Natural History of Various Types of Vascular Injuries and Potential Future Complications
