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. Pain 2. Pallor 3. Pulsenessness 4. Perishing cold 5. Paresthesia/anesthesia 6. Paresis/paralysis In other areas signs and symptoms of relevant organ ischaemia. e.g. cerebral, renal. Ect.

1. Hard A. Active bleeding B. expanding haematoma C. Distal ischemia ( P's) D. Bruit, thrill 2. Soft A. Haematoma B. injury close to known neurovascular bundle C. 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

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