Associate professor and consultant Vascular Surgery Vascular Trauma Badr Aljabri, MD, FRCSC Associate professor and consultant Vascular Surgery

General Principles Always start with ABC Large IV pore lines External compression to control bleeding Look for hard signs of arterial injuries

Try to answer !! Is this blunt or penetrating injury ? Is this Arterial or Venous injury ? Should I take the patient to the operating room or do further investigations? Is it Hospital Vs community based vascular injury?

Is this Arterial or Venous injury ? Pulse examination Hard signs Pulsetile ext. bleeding Absent distal pulses. Expanding hematoma Distal ischemia Thrill or bruit

Is this Arterial or Venous injury ? Low pressure dark blood external bleeding Non-expanding hematoma Shock is rare unless associated with arterial injury

Should I take the patient to the operating room or do further investigations? Any patients with these following signs should not wait !!!! External bleeding Expanding hematoma with shock Limb ischemia

Hospital based trauma Venous : Central venous access hematoma Guide wire dislodgment Arterial : catheterization - Psudoaneurysm - Arterial dissection & Thrombosis - AV Fistula formation - Distal Embolization

Psudoaneurysm walled off extra- luminal circulation of the blood as a result of arterial wall disruption.

Psudoaneurysm Conservative U/S guided compression U/S guided thrombin injection Surgery

Psudoaneurysm Indications for surgical intervention: 1) Evidence of ongoing bleeding 2) Associated limb ischemia 3) Nerve compression 4) Need for aggressive anticoagulation 5) Threatened skin viability 6) Psudoaneurysm surrounded by large hematoma 7) Expanding

Community based trauma Penetrating injury : most common cause Blunt trauma: associated with orthopedic injuries.

Extremity vascular injury 10% following penetrating ext. injury 1% following blunt ext. injury ( 25-75% of Popliteal are due to blunt trauma)

What should you do in OR? Keep in mind your inflow and outflow arteries Always think about your vascular conduit Be prepared to do on-table angiography Do not hesitate to call for help

What should you do in OR? Always establish good exposure Establish proximal then distal arterial control Use a shunt if the bones need to be fixed first to buy you some time Use local heparin flush Make your arterial repair tension-free Use autogenous vein Repair concomitant venous injury if patient is stable

What should you do in OR? Make your threshold low for “Fasciotomy”

Vein patch angioplasty

Tension-free primary repair

Interposition autogenous vein graft

Damage control Arteries that can be ligated with few consequences: The common and external carotid, subclavian, axillary , internal iliac arteries & Celiac axis. ICA ligation : 10-20% stroke rate. EIA,CFA & SFA: high risk of limb ischemia. SMA & IMA : gut necrosis

Damage control Almost all veins including the IVC can be ligated when necessary

Blunt Thoracic Aortic Trauma Deceleration injury. Multiple trauma victims It is lethal if not recognize and treated promptly Usually distal to left subclavian artery.

Neck Trauma Most commonly penetrating type. Associated vascular injury in > 30%

Assistant professor and consultant Vascular Surgery Thank You Badr Aljabri, MD, FRCSC Assistant professor and consultant Vascular Surgery