Vascular Trauma

1. Vascular Trauma General Surgery Teaching Rounds April, 2005

2. Overview Basic Principles Common Exam Questions Neck Chest Abdomen Extremities

3. Basic Principles Anatomy Types of Injury Mechanisms of Injury Clinical Manifestations Clinical Evaluation Investigations Management

4. Anatomy Know the named vessels � arterial and venous � in the vicinity of injury Know anatomic principles of proximal and distal control Appreciate the adjacent structures (nerves, organs etc)

5. Types of Injury Laceration Transection With or without defect Dissection Crush Thrombosis / Embolus Spasm

6. Mechanisms of Injury Penetrating Knife GSW/ Shrapnel (low/high velocity) Catheter (Iatrogenic) Blunt Direct (Contusion) Traction / Avulsion Deceleration Torsion

7. Clinical Manifestations Early Hemorrhage End-organ ischemia Fistula? Late Fistula False Aneurysm

8. Evaluation History and PE Type of weapon Time since injury 5 P�s Associated Injuries (neuro, MSK, GI, GU)

9. Evaluation �Hard� Findings Active Bleed Expanding Hematoma End-organ ischemia Loss of pulses A-V fistula �Soft� Findings Reduced pulses Neurologic deficits History of bleeding Shock Injury in proximity to major vessel

10. Investigations Plain Films Doppler Duplex Arteriography CT MRI

11. Arteriography Recall �hard� vs �soft� findings Role Detect occult injury Exclude need for OR Operative planning Endovascular Repair Other modalities may obviate or complement arteriography

12. Management Conservative Endovascular Operative Local � suture, patch, primary anast Bypass Anatomic, extra-anatomic Autogenous , prosthetic Adjunct Fasciotomies, MSK fixation

13. Common Questions

14. Neck Anatomy Carotid, Verterbrals, Subclavian Arteries Jugular, Subclavian, Innominate Mechanism >95% are penetrating Blunt injuries often complex Clinical Presentation Bleed, hematomas End-organ ischemia (brain)

15. Neck Penetrating Trauma � Zones I-III Zone I � base of neck, thoracic outlet to 1cm above clavicle Zone II � 1 cm above clavicle to angle of the jaw Zone III � above angle of mandible Who to image? Who to explore?

16. Neck Imaging 4 vessel angiography Duplex CT head Zone I and III are difficult to assess clinically � image the stable patient Zone II � issue of mandatory exploration open to debate (40-60% are negative), various algorithms of clinical re-evaluations, duplex and angiography

17. Neck Management Remember endovascular options (especially for zone III , +/- zones I,II) Repair in most (even if neuro deficit � could be metabolic, drug / alcohol) Ligate only if known severe cerebral injury (hemorrhagic infarct , diffuse cerebral edema) or complex injury with uncontrollable bleed

18. Chest Anatomy � Aorta, supra-aortic trunks, intercostals (including Adamkiwiecz), IVC, SVC, Innominate / subclavian (and Heart) Indication for Thoracotomy ER � penetrating, unstable, unresponsive to resuscitation, blood in chest tube Chest tube output >300 cc/hr for 2 or more hours 1500 to 2000 in 8 hours or less

19. Chest Exposures Posterolateral thoracotomy (traditional), good for L carotid, L subclavian and dec aorta but may reduce venous return, bleed into opp lung Median sternotomy � asc aorta, arch, innominate and branches Anterolateral thoracotomy � (4th i.s.) good for L side and ER control / resuscitation Other � clamshell, trapdoor, clavicular resection

20. Chest Aortic Tear / Disruption / Transection Deceleration and shear stress results in disruption anteriorly (opposite to ligamentum arteriosum) Dx � CXR, CT (angio), TEE, Angio (best?) CXR findings Widened medistinum, #ribs 1,2, #sternum, apical cap, pleural effusion, depression of L mainstem, tracheal deviation to R, obliteration of AP window, obliteration of descending aorta Repair Surgery � timing? Graft vs suture Endovascular

21. Abdomen Anatomy � Aorta and it�s branches � mesenteric, renals, iliacs. IVC and iliac veins, Portal circulation Review indications for laparotomy � peritonitis, DPL, imaging Operative principles 1st control bleeding and contamination Avoid complex vascular reconstruction whenever possible. Avoid prosthetics where possible Packing may be a good option (rewarm, resusciate and re-lap) Ligation and organ removal (spleen, one kidney) may be an option

22. Abdomen Control Options Supradiaphragmatic Supraceliac Infrarenal Balloons, Occlusion clamps Exposures Medial visceral rotation From left (Cattall) From right (Collis)

23. Abdomen Retroperitoneal Hematomas Penetrating (explore all?) Blunt (see below) Lim Zones 1-3 1 (central) explore all 2 (lateral) explore selectively (expansion, end-organ compromise) 3 (pelvic) best to pack (especially with fractures)

24. Extremities Most common vascular trauma Review and apply all basic principles (anatomy, type / mechanism of injury, clinical manifestation, evaluation, investigation) Goal � rapid re-establishment of circulation (where appropriate)

25. Extremities Operative Principles Proximal / distal control Primary repair where possible If graft / patch use autogenous Leg, contralateral limb Consider temporary shunt Fixation of ortho injuries Coverage of repair (muscle, soft tissue) Fasciotomies

26. Extremities Ligation may be OK in rare circumstances (proximal upper extremities, distal forearm, tibials) If significant associated MSK, neurologic injury amputation may be best Popliteal injuries have the highest amputation rate Vein repair may improve limb salvage � esp try to repair popliteal and common femoral veins. Repair vein before artery. Know the sequelae of compartment syndrome and reperfusion syndrome

27. Other Catheter injuries Intra-arterial drug injuries Cold Injury Frostnip �Chilblains� Immersion (Trench) foot Frostbite