Joel Arudchelvam

1.Sharp

knife shrapnel

2. Blunt

joint dislocation fracture

1.Transection / cut

2. Laceration

3.contusion

4.dissection

1.Bleeding / haematoma

2.Ischaemia

3.Complications of vascular injury (Refer later)

Bleeding

a. In extremities - obvious, may have stopped at the time of admission therefore a history of bleeding is important,haematoma (especially expanding)

b. In abdominal and thoracic arterial injury - hypotension

In extremities P's

1. Pain2. Pallor3. Pulsenessness4. Perishing cold5. Paresthesia/anesthesia6. Paresis/paralysis

In other areas signs and symptoms of relevant organ ischaemia. e.g. cerebral, renal. Ect.

1. Hard

A. Active bleedingB. expanding haematomaC. Distal ischemia ( P's)D. Bruit, thrill

2. Soft

A. HaematomaB. injury close to known neurovascular bundleC. History of bleeding

1.pain

could be due to injury itself, may not have pain due to associated

nerve injury

2.pallor

may be pale due to blood loss

3. Absent pulse

may be absent due to low blood pressure. Compare with othe limb.

4.paresthesia , paresis

may occur due to associated nerve, muscle injury or unresponsive

confused patient

limbs with paresthesia and paresis are in immediate threat and should be explored and repaired at theatre as soon as possible.

1.Doppler

Absent doppler signal indicates no flow, presence of doppler signal indicate there is flow in the vessel examined. Character of doppler may give a clue to the quality of flow i.e. Triphasic however this willnot exclude an injury. Also help to measure ABPI in both limbs for comparison

Duplex scan - difficult to perform in the setting of trauma due to incorporative patient, presence of wound and dressings and pain.

CT ANGIOGRAPHY - Helps to locate, to assess the extent of injury, to identify associated injuries and to plan the treatment.

On table angiography - in cases needing urgent exploration and having multilevel injuries. i.e trap gun injury

ABCD

Urgent exploration

Repair - Direct, interposition graft

Ligation – non important arteries and as a damage

control procedure

Urgent transfer after stabilisingABCD

FASCIOTOMY

Ischemia reperfusion injury

Compartment syndrome

Arteriovenous fistula

False aneurysm

Death

During ischaemia

Anaerobic metabolism – lactic acidosis

Reduced ATP – reduced activity of ion pump – accumulation of

intracellular Ca2+, Na+ and other ions, increased permeability

Ca2+ - activation of phospholipases and proteases

Activation of Xanthine oxidase

Increased membrane adhesiveness and Stasis leading to

prothrombotic effects

During reperfusion

Local Influx of O2 and cells

resulting in production of oxygen radicals Adhesion of cells leading to congestion and oedema

Systemic Acidosis Acute kidney injury ARDS Hyperkalemia Hypotension DIC

Revascularization as early as possible Fasciotomy and excision of dead muscle Heparinisation Hydration Oxygen Mannitol, allopurinol

Reduced organ / tissue perfusion as a result of increased intracompartmental pressure

Happen in tight compartments

Results in vicious cycle of ischemia and swelling and eventual muscle death

Early revascularisation

Elevation

Fasciotomy

Thank You