Arterial Injuries PDF

Arterial injuries Dr. Abdulwahab A AL-Makhathi  Arterial injury DEFINITION Sudden interruption of arterial supply ot the organ or limb by injury. INCIDENCE Common nowadays due to car accidents, war injuries , fall down or iatrogenic as invasive investigations. Etiology of arterial inju...

Arterial injuries Dr. Abdulwahab A AL-Makhathi  Arterial injury DEFINITION Sudden interruption of arterial supply ot the organ or limb by injury. INCIDENCE Common nowadays due to car accidents, war injuries , fall down or iatrogenic as invasive investigations. Etiology of arterial injury  Arterial injury AETIOLOGY Open injury : Stabs, bullets or iatrogenic Closed injury: Direct :  Plaster or tourniquet compression.  Road traffic accidents.  Arterial injury AETIOLOGY Indirect : Fracture or dislocations of bones. e.g. Supra-condylar fracture humerus with brachial artery injury. e.g. Supra-condylar fracture femur with popliteal artery injury.  Types of arterial injury without division ( No bleeding ) 1)Arterial spasm Due to arterial irritation by missile near the artery or canulation. Associated with intimal flap or artery Thrombosis or occlusion  Types of arterial injury 2)Arterial contusion The outer coat remain intact If associated with intimal tear + superadded thrombosis.  Types of arterial injury With division ( bleeding ) 1)Complete division Both ends bleed profusely but soon the bleeding decreases because of intima curls. media contracts. divided stumps retract. The pulse is lost distally.  Types of arterial injury with division ( bleeding ) 2)Partial division The bleeding will continue (pulsating haematoma) the bleeding does not stop because of contraction & retraction of arterial wall. The pulse is weak distally.  Mechanism of injury  Penetrating  Blunt  Iatrogenic Trauma to a blood vessel can produce  spasm  Intimal flap  Sub intimal hematoma  Thrombosis/occlusion  Hemorrhage  Laceration  Transection  A-V fistula Trauma to a blood vessel can produce  CLINICAL PICTURE History of trauma General Exam vital signs to evaluate the blood loss. Local Exam :  Investigations Blood investigation (CBC,RBS,KFT and cross matching) Plain X ray to detect foreign bodies (bullets) or fractures. Doppler & duplex to detect collaterals. Angiography (the most accurate) to localize site of traumatic A/V fistula Investigations  Management American college of surgeon developed the advanced trauma life support (ATLS) which include : 1)Primary survey. 2)Secondary survey. 3)Definitive treatment Management  Management (1)Primary survey.( Resuscitation ) ABCDE (A)Air way and cervical spine protection. (B)Breathing. (C)Circulation and hemorrhage control. (D)Disability. (E)Exposure and hypothermia prevention.  Management (2)Secondary survey.( Head to toe examination. Repeated re-evaluation. Transfer to definitive care  TREATMENT A- First aid treatment Temporary control of bleeding : by external compression or elevation or tourniquet of the limb. Anti-shock measures, antibiotics & analgesics. Heparin injuction. Associated fractures must be fixed to stabilize the repair.  TREATMENT B- Definitive treatment Immediate exploration & fasciotomy to prevent (compartmental syndrome) Then according to type of arterial injury (1)ARTERIAL INJURY WITHOUT DIVISION : [a] Arterial spasm : Intra-arterial injection of papaverine. If not successful : forcible dilatation by Fogarty catheter is performed. If not successful : Arteriotomy to detect intimal tear. If present then excise the spastic segment then graft is performed. [b] Arterial contusion : excision of contused segment then graft is performed.  TREATMENT (2)ARTERIAL INJURY WITH DIVISION : [a] Complete division: No gap : direct end to end anastomosis. Gap : Small artery : natural (saphenous vein) graft. Large artery : synthetic (Dacron or PTFE ) graft or bypass.  TREATMENT [b] Partial division : Longitudinal tear : Small artery : vein patch graft. Large artery : direct suture. Transverse tear : < 1/2 circumference : direct anastomosis > 1/2 circumference : turn it to complete then treat. TREATMENT  Intra-arterial drug injection AETIOLOGY 1- Drug addicts may wrongly inject drugs into arteries instead of veins. 2- Anesthetists may also wrongly inject thiopentone into an artery during induction of anesthesia. The most commonly punctured arteries are brachial & radial arteries.  Intra-arterial drug injection CLINICAL PICTURE Burning discomfort extending from the point of injection to the tips of the fingers Coldness & cyanosis soon follow. Digital gangrene may then develop.  Intra-arterial drug injection TREATMENT Heparin 10.000 IU intravenously to prevents thrombosis of small vessels. Dexamethazone 4 mg I.V / 6 hours to limits oedema. Low molecular weight dextran (dextran 40) to minimizes platelet aggregation. Strong analgesics. Amputation of digital gangern.  Acute Compartmental syndrome Definition : Is a condition in which increased pressure within a closed compartment compromises the circulation and function of tissues within that space. Acute limb compartment syndrome : Is acutely raised pressure in an osseo-facial compartment of a limb. It is most seen in leg or forearm but can occur in thigh , buttock , foot or arm.  Limb Compartmental syndrome Anatomy Thigh 3 Leg 4 Foot 4 Arm 2 Forearm 4 Hand 5  Limb Compartmental syndrome Common cases : Ischemia and reperfusion injury. Combined arterial and venous injury. Bone fracture. Tight bandage or plaster cast. Circumferential burn with Escher. Limb Compartmental syndrome  Limb Compartmental syndrome MENEGEMENT Remove restricting bandage or cast. Avoid elevated the affective limb. Rehydrated the patient with diuretics. Fasciotomy. Limb Compartmental syndrome