Vascular trauma

Question 1

Outline the causes of peripheral vascular trauma

Answer 1

Penetrating wounds: gunshot, stab, IVDU
Blunt trauma: joint displacement, fracture, contusion (bruise)
Invasive procedure: angiography, cardiac catheterisation, balloon angioplasty

Question 2

What are the hard signs of arterial injury, and what do these indicate?

Answer 2

External arterial bleeding
Rapidly expanding haematoma
Palpable thrill, audible bruit
Obvious acute limb ischaemia - not corrected by reduction of dislocation or realignment of fracture

These indicate definite injury to an artery ➔ require immediate surgery

Question 3

What are the soft signs of arterial injury, and what do these indicate?

Answer 3

History of bleeding at the scene
Proximity of penetrating wound or blunt trauma to a major artery
Diminished unilateral pulse
Small non-pulsatile haematoma
Neurogenic deficit

Probable injury to an artery ➔ may require investigation (duplex USS or angiography)

Question 4

Which fractures/dislocations have a higher incidence of associated vascular injury?

Answer 4

Supracondylar humerus fracture in children ➔ brachial artery
High tibial ‘bumper fracture’ ➔ anterior tibial artery
Dislocation of knee ➔ popliteal artery

Question 5

Outline the principles of fluid resuscitation in peripheral vascular trauma

Answer 5

Adequate IV access
Access into uninjured limb
Avoid lines leading to potential areas of tamponade or venous injury
Preserve saphenous or cephalic veins

Question 6

Outline the management of peripheral vascular trauma

Answer 6

Majority require surgical exploration and repair
Aims: control life-threatening haemorrhage, and prevent limb ischaemia
Warm ischaemia time of 6hr - after this limb survival is unlikely
After 8hr - organ damage

Question 7

What is the commonest cause of chest vascular trauma?

Answer 7

Rapid deceleration ➔ disruption of descending thoracic aorta

Question 8

Name 2 common emergency pathologies seen alongside chest vascular trauma?

Answer 8

Tension pneumothorax

Cardiac tamponade

Question 9

Describe the prognosis of chest vascular trauma?

Answer 9

90% mortality in thoracic aorta damage prior to reaching hospital
25% mortality within 24hr of reaching hospital

Question 10

What investigation is used for stable patients with chest vascular trauma?

Answer 10

CT scan - locates arterial trauma

Question 11

What is the treatment of chest vascular trauma?

Answer 11

Stent graft

Question 12

Name 3 causes of retroperitoneal bleeding

Answer 12

Pelvic fracture
Pelvic surgery
Ruptured AAA
Spontaneous bleed - Warfarin
After angiography/angioplasty - femoral puncture

Rare: Wunderlich syndrome (spontaneous non-traumatic renal haemorrhage ➔ acute flank pain + flank mass + hypovolaemic shock)

Question 13

What are the clinical signs of retroperitoneal bleeding?

Answer 13

Following femoral artery catheterisation
Acute abdominal/flank pain
Hypotension
Anaemia

Often no associated haematoma at groin puncture site
Iliac fossa mass/tenderness

Question 14

What investigation is required to confirm retroperitoneal bleeding?

Answer 14

CT scan

Question 15

Outline the medical management of retroperitoneal bleeding

Answer 15

IV fluid resuscitation + Blood transfusion
Reverse anticoagulation therapy
Correct clotting disorders
Inform vascular surgeon

Question 16

Outline the definitive management of retroperitoneal bleeding

Answer 16

Endovascular:

• Stent graft
• Arterial embolisation

Surgical decompression (rare)

Question 17

Name the retroperitoneal organs

Answer 17

Suprarenal glands (aka the adrenal glands)
Aorta/IVC
Duodenum (2nd and 3rd segments)
Pancreas (head, neck, and body)
Ureters
Colon (ascending and descending colons)
Kidneys
Esophagus
Rectum