Vascular Surgery – Vascular Injury: By Adam Power M.D. and Yiting Hao R.N.

October 10, 2019 0 By Jose Scott

Vascular injury, both as penetrating or blunt
trauma, can be a life-threatening presentation to the emergency room and is often complicated
by non-apparent hemorrhage, for instance into the retro-peritoneal space. Left untreated, vascular injuries can lead
to hemorrhagic shock, thrombosis, and compartment syndrome. Blunt vascular injuries occur frequently during
motor vehicle collisions, and commonly affect the thoracic and abdominal aorta. Blunt aortic injury is thought to occur following
rapid deceleration and tearing of the aorta distal to the origin of the left subclavian
artery. [Parmley, 1958] Penetrating trauma causes
crushing and separation of tissues along the penetrating object and often affects the extremities. This type of injury is mostly associated with
gunshot and knife wounds. On initial presentation be sure to follow
the ATLS guidelines and complete a systematic primary assessment, using the ABDCDE approach. Treatment priority is based on injuries, vitals
and injury mechanism. The primary goals of intervention are to locate
the bleeding, stop it, and restore intravascular volume while maintaining homeostasis through
a functional blood composition. Remember, the clinical features of a patient
with blunt vascular trauma may range from asymptomatic to severe hypotension and shock. It is essential to keep in mind the sources
of severe and life-threatening hemorrhage. ATLS guidelines suggest to look for “blood
on the floor and then four more” (chest, abdomen, pelvis/retroperitoneum, and long
bones). In the extremities, the most common presentation
of arterial injury is acute ischemia. Hard signs of arterial injury are: an audible bruit or palpable thrill
pulsatile hematoma expanding hematoma
active bleeding signs of ischemia The classic 5 P’s of acute limb ischemia
include: Pain
Pallor Paralysis
Paresthesia Pulselessness
We then investigate more thoroughly with a secondary assessment, using FAST scans, as
well as pelvic, chest and abdominal x-rays. Laboratory studies are essential for monitoring
these patients: Blood group and crossmatch is sent quickly
but patients often require O negative blood due to urgency. Complete blood count to monitor hemoglobin
is useful in slow bleeding, and is typical obtained every 6 hours in series. It is of limited used in acute severe hemorrhage. Coagulation parameters must be assessed and
any anti-coagulation medication the patient has been taking must be reversed. Coagulopathy may be observed in a trauma patient
following acidosis, hypothermia, and hemodilution following aggressive intravascular resuscitation. Compartment syndrome is a serious complication
associated with vascular injuries and needs to be monitored after limb ischemia and then
reperfusion. It is the increase in intracompartmental pressure
that impairs tissue perfusion and can lead to tissue death. Although this is a clinical diagnosis, creatinine
kinase and myoglobin in addition to renal function, must also be monitored with increased. Tell-tale clinical signs include: Pain out of proportion to injury not relieved
by analgesicsPain with contraction of compartment Pain with passive stretch
Severe swelling Loss of arterial pulse is a late finding Therapy is often dependent on the hemodynamic
status. While expectant management can be reserved
for intimal tears and some small pseudoaneurysms, definitive therapy in the form of operative
or endovascular repair is reserved for injuries penetrating the outer vessel wall or occluded