Vascular Emergencies

Question 1

3 ways in which peripheral vascular trauma may occur?

Answer 1

penetrating wounds
blunt trauma
invasive procedures

Question 2

examples of penetrating wounds?

Answer 2

stab
gunshot
IV drug abuse

Question 3

examples of blunt trauma?

Answer 3

bone fracture
joint displacement
contusion

Question 4

examples of invasive procedures which can cause peripheral vascular trauma?

Answer 4

balloon angioplasty
cardiac catheterisation
arteriography

Question 5

hard signs of arterial injury?

Answer 5

external arterial bleeding- pulses of blood
rapidly expanding haematoma- may be visualised on USS
palpable thrill, audible bruit
obvious acute limb ischaemia- pale, cold, pain, pulsless, paraesthesia, paralysis, and this is not corrected by reduction of dislocation or realignment of fracture.

Question 6

what is required in ptnts with hard signs of arterial injury e.g. external bleeding, haematoma, obvious acute limb ischaemia?

Answer 6

surgery!

Question 7

soft signs of arterial injury?

Answer 7

diminshed unilateral pulse
small non-pulsatile haematoma
history of bleeding at scene
proximity of penetrating wound or blunt trauma to major artery

Question 8

how might ptnts with soft signs of arterial injury be assessed?

Answer 8

serial examination*
duplex USS
arteriography

ask vascular surgeon if in doubt!

Question 9

how long can a limb survive before extensive tissue necrosis occurs in complete acute ischaemia, making a limb unsaveable?

Answer 9

6 hours

primary amputation may be required in severely traumatised limb

Question 10

how should fluid resucitation take place if peripheral vascular trauma?

Answer 10

adequate IV access lines, not placed in affected limb or extremities that would lead fluid directly into potential areas of tamponade or venous injury.

Question 11

which veins should not be used for IV fluid resuscitation in peripheral vascular trauma?

Answer 11

great saphenous
cephalic
as these may be needed for repair

Question 12

why might diagnostic studies be needed in a vascular emergency?

Answer 12

localise vascular injury to plan an operative approach
avoid unnecessary op
document presence of surgical lesion

Question 13

which limb fractures have a higher incidence of assoc. vascular injury?

Answer 13

supracondylar fracture of humerus in children
knee dislocation
high tibial ‘bumper fracture’

Question 14

what generally takes higher importance over limb trauma?

Answer 14

severe head injuries and life-threatening haemorrhage from chest or abdomen

Question 15

how can arterial trauma be accurately identified in stable ptnts following chest trauma?

Answer 15

CT scan

Question 16

what clinical signs suggest a RP bleed following femoral artery catheterisation?

Answer 16

Hypotension or drop in Hb following femoral artery catheterisation procedure
Patient may complain of lower back pain
Quite often there is no associated haematoma at groin puncture site
Patient may have iliac fossa mass/tenderness

Ptnt will need resuscitation-replace blood loss

Question 17

what is exsanguination?

Answer 17

losing blood to a degree which is sufficient to cause death

Question 18

Most important 1st step to management of any ptnt in this setting?

Answer 18

ABCDE
airways- chin lift or jaw thrust to open, protect C spine, endotracheal tube may be used if obstruction
breathing-inspect, palpate, percuss and auscultate chest
circulation- compression- use hand, to control bleeding, IV lines
disability- AVPU, GCS
environmental control+exposure- undress ptnt, keep them warm.

Question 19

compartments of the leg?

Answer 19

anterior
lateral
posterior- superficial and deep

Question 20

compartment syndrome more common in young or old?

Answer 20

young- more muscle mass- increase pressure in compartment

Question 21

non-arterial causes of an acute limb pain of sudden onset?

Answer 21

venous thrombosis

SC compression or infarction

Question 22

causes of acute arterial limb ischaemia?

Answer 22

arterial embolus e.g. post MI or due to AF
thrombosis on an atheromatous plaque- ptnt may have already experienced IC or rest pain
thrombosis of an aneurysm
arterial dissection- aortic- severe chest and /back pain, other pulses e.g. L subclavian absent.
traumatic disuption
external compression e.g. a cervical rib

Question 23

symptom triad in ruptured AAA?

Answer 23

collapsed
shock- hypotension, tachycardia, cold, clammy
sudden onset back/abdom. pain

Question 24

DDs for ruptured AAA?

Answer 24

MI
acute pancreatitis
perforated duodenal ulcer
ureteric colic
aortic dissection

Question 25

emergency management of ruptured AAA?

Answer 25

need vascular surgeon and experienced anaesthetist, warn theatre
ECG, take blood for amylase, Hb, crossmatch (may eventually need 10-40U!!), urinary catheter
2 large IVIs. Treat shock with ORh-ve blood, but keep systolic BP 100mmHg or less
take ptnt straight to theatre
give prophylactic antibiotics- cefuroxime 1.5g and metronidazole 500mg IV
surgery- aorta clamped above leak, Dacron graft inserted- replace ruptured aorta