Vascular Trauma

Frank Schmieder, M.D.

Section of Vascular Surgery
Temple University Hospital
 Vascular Trauma
Bloody vascular trauma - its either bleeding
too much or its not bleeding enough
Hemorrhage
Ischemia
Limb Loss, Stroke, Bowel Necrosis, Renal Failure

Multi-organ System Failure

Immune Response
 Vascular Trauma

Context
Types & Mechanism
Basic Principles
Evaluation & Management
 Epidemiology
Leading Cause of Death Under Age 40
Males Between 20 & 40
Prevention
Conflict: I was on my way to church
Accidental: Seatbelts/Helmets, Safety Rules
Impact of Trauma System Approach
ATLS
 Mechanism of Injury
Accidental
Penetrating: GSW, Shrapnel, Knife
Blunt: Contusion, Traction, Avulsion
Iatrogenic
Central Lines, General Vascular
Access, Catherizations, Chest Tubes,
Endoscopy, Embolizations
 Mechanism of Injury

San Diego & Houston Trauma Registry

Types of Injury
 Basic Principles
ATLS
History
Physical Examination
Golden Period
Decision towards operation, investigation
or observation
 Basic Principles
Hard Signs of Vascular Injury
Pulsatile Bleeding
Expanding Hematoma
Palpable Thrill
Audible Bruit
Evidence of Regional Ischemia
Paresthesia, Paralysis, Pulselessness,
Pallor, Pain, Poikilothermia
 Basic Principles

Soft Signs of Vascular Injury

History of Moderate Hemorrhage
Proximity of Injury to Major Artery
Diminished but Palpable Pulses
Neurologic Deficits
 Evaluation
Doppler Probe
ABI

Duplex Ultrasonography
Screening

Angiography
Gold standard

CT, MRI, Plain Films

Evaluation
Vascular Trauma
 Learning From Conflict
Endovascular Therapy, Shunting, Permissive
Hypotension, Damage Control Surgery
Iraq, Afghanistan, Balkans, Urban Trauma Centers

Bypass, Prosthetic & Autogenous

Korea, Vietnam, Urban Trauma Centers
Resuscitation, MASH Units, Vessel Repair
World War II, Korea
Ligation, Hemostasis, Infection
World War I, Ancient History
 Management - Principles
Hemorrhage Control
Digital, Tourniquet, Balloon Catheters
Volume Resuscitation
Access, Fluids, Blood Products
Early & Following Repair
Technical Principles
Proximal & Distal Control
Ligation & Shunting
 Management - Surgery
Repair by Direct Suture
End to End, Primary Anastomosis
Patch Angioplasty
Bypass: Autogenous, Prosthetic
Interposition, End to Side
Endovascular Techniques
Covered Stents, Coils
Management - Surgery
Management - Surgery
Management - Surgery
Management - Surgery
Management - Surgery
Management - Surgery
Management - Surgery
Management - Surgery
Management - Surgery
Management - Surgery
Management - Surgery
Management - Surgery
Management - Surgery
 Management - Surgery
Ligate With Impunity
External Carotid, Internal Iliac, Tibials, Radial, Ulnar
Ligate but Worry
Common Carotid, External Iliac, IVC, Mesenterics,
Celiac, Portal Vein, Subclavian, Axillary
Do Not Ligate
Internal Carotid, Renal Arteries
 Management - Surgery
Amputation
Mangled Extremity
Neurologic Injury
Reperfusion
Irreversible Ischemia, Rigor
Popliteal Injuries:
Highest Amputation Rate
 Management - Surgery
Fasciotomy
Indications
Anatomy
Procedure
Wound Care
Follow Up
 Management
Reperfusion Injury
Release of
Inflammatory Mediators, Oxygen Radicals & Other
Intracellular Material, Lactic Acid, Potassium
Leading to
Myocardial Depression, Generalized Vasodilatation,
Systemic Inflammatory Response Syndrome
 Management
Acute Renal Failure
Myoglobinuria
SIRS
Thrombosis & Anticoagulation
AV Fistula, Pseudoaneurysms
Chronic Venous Insufficiency
 Conclusions
Prioritize & Stabilize
Identify Patients in Need of Surgery
Minimize Time to Repair
Remember Surgical Principles
Anticipate & Manage Complications
TUH Hybrid Suite