Vascular Trauma Flashcards
State some potential causes of peripheral vascular trauma
- Penetrating wounds
- Gunshot
- Stab
- IV drug abuse
- Blunt trauma
- Joint displacement
- Bone fracture
- Contusion (bruise)
- Invasive procedures
- Arteriography
- Cardiac catheterisation
- Balloon valvuloplasty
What do we mean by hard and soft signs of arterial injury?
- Hard signs= indicate presence of major vascular injury therefore immediate surgery is required
- Soft signs= indicate there might be a major vascular injury hence additional observation & diagnostic tests are required
State the 4 hard signs of arterial injury
- External arterial bleeding
- Rapidly expanding haematoma
- Palpable thrill, audible bruit
- Acute limb ischaemia (not corrected by reduction of dislocation or realignment of fracture)
State the 5 soft signs of arterial injury
- History of bleeding at the scene
- Proximity of penetrating wound or blunt trauma to major artery
- Diminished unilateral pulse
- Small non-pulsatile haematoma
- Neurogenic deficit
What investigations may be required for a pt with soft signs of arterial injury?
- Serial examination
- Duplex scan
- Arteriography (CT or MRI)
We have said that soft signs of arterial injury indicate there may be a major vascular trauma. Why are diagnostic studies done when a pt has soft signs of arterial injury?
- To prevent unnecessary operation
- Document presence of surgical lesion
- Localise vascular injury to plan operative approach
Certain limb fractures have a higher incidence of associated vascular injury; state 3
- Supracondylar #humerus in children
- High tibial ‘bumper fracture’
- Dislocation of knee
State some key principles of cannula insertion and fluid resuscitation in peripheral vascular trauma
- Gain adequete IV access (two large bore cannulas)
- Place lines into an uninjured upper or lower extremity
- Avoid placing cannulas into extremities as this will lead fluid directly to areas of tamponade or venous injury
- Preserve saphenous or cephalic veins (may be needed for repair)
Discuss the general principles of management of a peripheral vascular injury in the limb
Blunt injuries to major intrathoracic vascular structures present as a major challenge in both diagnosis and management. May require immediate management for tension pneumothorax and/or tamponade. If the pt is stable, what imaging would we do to help identify the arterial trauma?
CT scan
What is the most common intra-thoracic vascular injury?
Discuss its prognosis
- Disruption of the descending thoracic aorta at its isthmus- caused by rapid deceleration
- Prognosis:
- 90% die before reach hospital
- Of those reaching hospital 25% die within first 24hrs
State some causes of retroperitoneal bleeds
- Pelvic fractures
- Surgery in the pelvis
- Spontaneous (warfarin therapy)
- Following angiogram/angioplasty
State some signs & symptoms of peritoneal bleed
- Hypotension or drop in Hb
- Lower back pain
- May have iliac fossa mass/tenderness
- History of cause of peritoneal bleed e.g. had cardiac catheterisation
Discuss the management of retroperitoneal bleeds
- Fluid resuscitation
- Alert vascular surgeons
- Urgetn CT to confirm diagnosis
- Surgical repair or radiological intervention
Draw and label the different segments/sections of the aorta
Draw and label the aortic arch
What is an aortic dissection?
Tear in the tuica intima of aorta resutling in blood flowing between, and splitting apart, the tunica intima and tunica media
State some risk factors for aortic dissections- highlight the most important risk factor
- Hypertension
- Trauma
- Atherosclerotic disease
- Male
- Connective tissue disorders e.g. Marfan’s syndrome, Ehlers-Danlos syndrome
- Bicuspid aortic valve
- Pregnancy
- Syphilis
Who are aortic dissections more common in?
*Think about gender, age and underlyiing disorders
- Males
- 50-70yrs
- Connective tissue disorders e.g. Marfan’s, Ehlers-Danlos syndrome
Aortic dissections can be acute or chronic; explain the difference
- Acute= diagnosed =14 days
- Chronic= diagnosed >14 days
Discuss signs & symptoms of aortic dissection
Tearing chest pain that typically radiates to back
- Tachycardia
- Hypotension or hypertension (depending on if there is rupture)
- New aortic regurgitation murmur
- Pulse deficit (weak or absent carotid, brachial or femoral pulse)
- Variation(>20mmHg) in systolic BP between arms
- Limb ischaemia
- Hemiplegia is carotid artery supply affected
- Paraplegia if anterior spinal artery supply affected
- Anuria if renal artery supply affected
Aortic dissections can progress distally or proximally or in both directions; what do we call it if it progresses:
- Proximally
- Distally
- Proximally: retrograde (towards aortic valve)
- Distally: anterograde (towards iliac arteries)
Explain how retrograde aortic dissections can cause cardiac tamponade
- Retrograde propagation can result in prolapse of aortic valve
- Bleeding in the pericardium
- and hence cardac tamponade
State the two systems that can be used to classify aortic dissections
- Stanford
- DeBakey
Both classify anatomically
Describe the Stanford classifcation of aortic dissections
- Group A: involves ascending aorta and can propagate to aortic arch and descending aorta. Tear can originate anywhere along this path (⅔ of cases)
- Group B: descending aorta distal to left subclavian origin (⅓ cases)
Describe the DeBakey classification of aortic dissections
- Type 1: originates in ascending aorta and propagates at least to the aortic arch (typically in pts >65yrs and carries highest mortality)
- Type 2: originates in and is confined to the ascending aorta (typically in elderly pts with hypertension & atherosclerotic disease)
-
Type 3: originates distal to the subclavian artery in the descending aorta
- 3a= extends to diaphragm
- 3b= extends into abdominal aorta
Summarise how Stanford and DeBakey classification of aortic dissections overlap
What type of shock is seen in aortic dissections?
Could be:
- Hypovolaemic: due to blood loss
- Cardiogenic: due to severe aortic regurgitation or pericardial tamponade
What investigations would you do if you suspect a pt has an aortic dissection, include:
- Bedside
- Bloods
- Imaging
Bedside
- ECG: cardiac pathology
- ABG
Bloods
- FBC:
- U&Es:
- LFTs:
- Troponin:
- Coagulation:
- Crossmatch at least 10 units (according to oxford handbook)
Imaging
- CT angiogram of chest, abdomen & pelvis (INVESTIGATION OF CHOICE)
- Consider transoesophageal echo (if pt too unstable to go to CT)
- CXR may show widened mediastinum (not most useful)
What finding on CT angiogram of chest, abdo & pelvis suggests aortic dissection?
False lumen
Discuss the immediate management of aortic dissections (regardless of type)
- High flow oxygen
- IV access (2 large bore cannulas)
- CAREFUL fluid resuscitation; if hypotensive keep bp at 100-110
- Contact vascular surgery and ITU
*if there has been a rupture then target BP should be enough for cerebral perfusion only. If it is uncomplicated dissection then target BP should be below 110mmHg
Discuss the management (following initial management) of:
- Type A dissections
- Type B dissections- uncomplicated
- Type B dissections- complicated
- Stanford type A: replace with synthetic graft
- Stanford type B- uncomplicated: medical management with beta blockers to decrease BP and Hr to minimise stress of dissection and limit propagation
- Stanford type B- complicated: surgical repair e.g. with stent
Type B dissections can go on to be chronic; true or false?
True; can have continued leakage into dissection (even if stent is placed). Most common complication of chornic disease is an aneurysm.
State some potential complications of aortic dissections
Complications backward tear:
- Aortic rupture
- Aortic regurgitation
- Cardiac tamponade
- Myocardial infarction (inferior pattern due to RCA involvement)
Complications of forward tear:
- Stroke or paraplegia (if cerebral or spinal artery involvement)
- Renal failure
What do we mean by a complicated aortic dissection?
Complications have arisen such as:
- Rupture
- Renal, visceral or limb ischaemia
- Uncontrollable hypertension
