taem10:acute arterial occlusion
DESCRIPTION
นพ.ประสิทธิ์ วุฒิสุทธิเมธาวีนพ.ประเสริฐ วศินานุกรTRANSCRIPT
Acute arterial occlusion11 Feb 2009
นพ.ประสิ�ทธิ์� วุ ฒิ�สิ ทธิ์�เมธิ์าวุ�นพ.ประเสิร�ฐ วุศิ�นาน กรหน�วุยเวุชศิาสิตร�ฉุ กเฉุ�นคณะแพทยศิาสิตร� มหาวุ�ทยาลั!ยสิงขลัานคร�นทร�
BackgroundCommon in ED
Embolus;
- MI
- mitral valve dis.
- AF
Thrombosis: chronic (skin change, muscle
atrophy)Schwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005
Diagnosis
History
Physical examination
- 6PS
- chronic arterial occlusion
Investigations
- doppler USG
- angiogram / CTASchwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005
HistoryAcute VS Chronic
Underlying disease: DM, HT, heart dis.
6Ps
TraumaRosen’s Emergency medicine concepts and clinical practice. 6 th ed. Philadelphia: Mosby; 2006
6PsPain
Pallor
Pulseless
Poikilothermia
Paresthesia
ParalysisSchwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005
Investigations
Color doppler USG
Angiography
- gold standard
- abnormal filling defect
CT angiogram
MRI / MRASchwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005
TreatmentOrgans / Limbs salvage: within 6 hours
Prevent complications
- compartment syndrome
- reperfusion injury Schwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005Sabiston textbook of surgery the biological basic of modern surgical practice. 18th ed. Philadelphia: Saunders; 2008
TreatmentGeneral
- Pain relief
- Pre-operative evaluation
- Correct metabolic imbalance
- Treat underlying dis. Schwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005Sabiston textbook of surgery the biological basic of modern surgical practice. 18th ed. Philadelphia: Saunders; 2008
TreatmentHeparinization (80/18)
- 80 units/Kg. IV bolus (5,000 units)
- 18 units/Kg/hr IV infusion
- Keep PT & INR 1.5 -2.5Schwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005Sabiston textbook of surgery the biological basic of modern surgical practice. 18th ed. Philadelphia: Saunders; 2008
TreatmentAll cases need pre-operative angiogram
Arterial exploration/endovascular technique
- forgathy embolectomy
- thrombectomy
- bypass graft
Vascular traumaCoincidence with others injury
- long bone fracture / dislocation
- penetration
Male (72-90%)
Peak 20-40 years old (90%)Schwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005Rosen’s Emergency medicine concepts and clinical practice. 6th ed. Philadelphia: Mosby; 2006
MechanismPenetration (70-90%)
Blunt trauma including blast injury
Iatrogenic injury esp. vascular intervention
Peripheral vascular injury. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill; 2008
“ Bleeding to shock or not
bleeding enough”
PathophysiologyCompleted occlusive injury
- Transection: bleeding or bloodless
- Thrombosis
- Reversible vasospasm
Peripheral vascular injury. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill; 2008
PathophysiologyNon-occlusive injury
- Intimal flap
- Pseudoaneurysm
- Arteriovenous fistula
- Compartment syndrome
Peripheral vascular injury. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill; 2008
Signs & Symptom
s6Ps
Association injury
Hard signs
Soft signs
Hard Signs Expanding / pulsatile hemaotma
Pulsatile bleeding
Palpable thrill
Audible bruit
Pulseless บาดเจ็�บหลอดเลอดแขนขา . ศั�ลยศัาสตร์�ฉุ�กเฉุ�น 2538Pitfalls and Management of Peripheral Vascular Injury. ศั�ลยศัาสตร์�วิ�วิ�ฒน� 26, 2544
Soft Signs Large non-expanding / non-pulsatile hemaotma
Isolated nerve injury
Diminish pulse
Prolong capillary refill
บาดเจ็�บหลอดเลอดแขนขา . ศั�ลยศัาสตร์�ฉุ�กเฉุ�น 2538Pitfalls and Management of Peripheral Vascular Injury. ศั�ลยศัาสตร์�วิ�วิ�ฒน� 26, 2544
Soft Signs Proximity to nerve bundle (< 1 cm.)
Trajectory crossed neurovascular bundle
Unidentified cause of shock
Long bone fracture and dislocation
บาดเจ็�บหลอดเลอดแขนขา . ศั�ลยศัาสตร์�ฉุ�กเฉุ�น 2538Pitfalls and Management of Peripheral Vascular Injury. ศั�ลยศัาสตร์�วิ�วิ�ฒน� 26, 2544
History Time of injury (< 6 hrs limbs salvage)
Mechanism of injury
- Penetration
- Crush
- Blunt
Factors affect wound healing
Physical examination ABCDE
Others association injury
6Ps
Neurologic examination
Pulse oximetry
Ankle Brachial Index (ABI)
Good collateral circulation
Congenital absence pulse
Generalize vasospasm
Pre-existing vascular disease
Mistakes
Pulse examinatio
n Compare both sides
Intensity: normal 2+
Palpate
Hand held doppler
Pulse examination
Pulse Right Dop Left Dop– Femoral + + ++ +
++– Popliteal - + + ++– Posterior tibial - + + +
+– Dorsalis pedis - + + +
+
Ankle Brachial Index (ABI) Screening test esp. soft signs
sBP ankle / sBP brachial
Ankle Brachial Index (ABI) Result
- 0.9-1.2 : normal
- 0.7-0.89 : mild arterial insufficiency
- 0.5-0.69 : moderate arterial insufficiency
- < 0.5 : severe arterial insufficiency
Schwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005Sabiston textbook of surgery the biological basic of modern surgical practice. 18th ed. Philadelphia: Saunders; 2008
Limitations of ABICan not evaluate venous injury
Can not detect deep artery injury
False positive in calcified vessels
Schwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005Sabiston textbook of surgery the biological basic of modern surgical practice. 18th ed. Philadelphia: Saunders; 2008
InvestigationsPlain X-rays: fracture / dislocation
Hand held doppler: arterial waveform
Color doppler USG: arterial blood flow
CTA / MRA
Arteriography: gold standard
AngiographyDecrease rate of negative vascular exploration
Indications
- Soft signs
- Multiple site injury
Pre-operative or intra-operative Peripheral vascular injury. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill; 2008
TreatmentOrgans / Limbs salvage: within 6 hours
Prevent complications
- compartment syndrome
- reperfusion injury
TreatmentGeneral
- ABCDE
- Initial resuscitation
- Stop bleeding
- Pre-operative evaluation
TreatmentMajor vascular injury
- treat within 6 hrs
- temporary vascular shunt
- vascular exploration and repair
- percutaneous embolization
- endovascular repairPeripheral vascular injury. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill; 2008บาดเจ็�บหลอดเลอดแขนขา . ศั�ลยศัาสตร์�ฉุ�กเฉุ�น 2538Pitfalls and Management of Peripheral Vascular Injury. ศั�ลยศัาสตร์�วิ�วิ�ฒน� 26, 2544
TreatmentVenous injury
- Mainly simple ligation
- Vascular exploration and repair
TreatmentMinor vascular injury
- Spontaneous stop (85%); intimal flap < 5 mm.,
pseudoaneurysm < 5 m. diameter
- Vascular exploration esp. child, active bleeding
- Simple ligationPeripheral vascular injury. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill; 2008บาดเจ็�บหลอดเลอดแขนขา . ศั�ลยศัาสตร์�ฉุ�กเฉุ�น 2538Pitfalls and Management of Peripheral Vascular Injury. ศั�ลยศัาสตร์�วิ�วิ�ฒน� 26, 2544
Peripheral vascular injury. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill; 2008
Conclusion
Common in ED
Careful history taking: Acute VS Chronic
Physical examination: Hard-soft signs, ABI
Limb salvage treatment
Thank you for your attention