emergencies in vascular and transplant surgery
TRANSCRIPT
Dr. Joel Arudchelvam Consultant Vascular and transplant surgeon
Teaching Hospital Anuradhapura
Pre intern training programme Nov 2015 Teaching Hospital Jaffna.
Some Vascular Emergencies
Acute limb Ischaemia
Vascular trauma
compartment syndrome
Acute limb Ischaemia
Sudden interruption of blood supply to limb resulting in threat to the limb viability.
Acute limb Ischaemia
Inside the vessel Embolus
on the wall of vessel ThrombosisTraumaDissection
Compression from outsideTight bandage, cast, tourniquetCompartment syndromeBurn
Acute limb Ischaemia
Inside the vessel Embolus
on the wall of vessel ThrombosisTraumaDissection
Compression from outsideTight bandage, cast, tourniquetCompartment syndromeBurn
Acute limb Ischaemia
Patient presentation With evidence of ischaemia (P’s)
pain - which is severe and sudden onsetpallorPerishing coldPulselessnessParesis / paralysisParaesthesia / anaesthesia.
Acute limb Ischaemia
Management
Recognize Start unfractionated heparin
Loading dose 75 – 100 IU/Kg ( approximately 5000 IU ) Followed Infusion of heparin -18U/kg (approximately -1000U/hr)
Pain reliefKeep fasting Check the Viability of the limb - note.Acute limb ischemia is a clinical diagnosis -there is no
need of imaging.Arrange transfer (after discussing/fasciotomy)
Acute limb Ischaemia
Interventions:-
Embolectomy – using balloon tipped Fogarty catheter + /- Fasciotomy Continue heparin (infusion 18U/kg) until the INR is 2-3
for 2 days Start warfarin – adjust dose to keep INR between 2-3 Monitor distal pulse and for effects of reperfusion
Vascular traumaSigns of a vessel injury Hard signs
Active bleeding Thrills, Bruits Signs of distal ischemia
Absent pulse Pain Pale Perishing Cold Paresthesia / anaesthesia Paresis / Paralysis
Expanding hematoma
Soft signs Hematoma Injury close to a known neurovascular bundle
paresis/ paralysis and paresthesia / anaesthesia - late signs Paresis and paresthesia - viability of the limb is in immediate threat anaethesia and paralysis -not viable.
Vascular trauma
Management
Patients with vascular injury often have associated injuries
–resuscitation
If patient has hard signs – no need of imaging - send to
OT immediately/ transfer after discussing.
Soft signs - monitor
Compartment syndrome
Reduced organ perfusion due to increased intra compartment pressure.
Causes;Trauma (muscle contusion)HaematomaReperfusion Intracompartmental extravasation of fluidsTight bandage, cast
Compartment syndrome
Clinical features
Excessive pain - pain on passive movements of the muscles.
Numbness -e.g. anterior compartment results in numbness at first toe web i.e. deep peroneal nerve distribution)
Tense swollen compartment
Compartment syndromeTreatment
Recognize
Remove the cause
Surgery – fasciotomy
Thank You