VASCULAR TRAUMA

W. Binafsihi

RSPAD
Gatot Soebroto

Jakarta

combined vascular-skeletal trauma

0.2% of all trauma 10%-15% blunt limb vascular trauma 0.3%-3% limb arterial injury of all FXs 10%-70% amputation rate
Howe, Am Surg 1987;53-205 Attebery, J A C S 1996;183:377

89MF/10yrs

rural 10.000sqmiles

Traffic Farm/Industrial Gun, knives etc

Kolvunen D Nichols K Silver D University of Missouri Health Sciences Center U.S.A. Surgery 1982; 91(6):723-727

34% arteriography 33% oamputations 13 1 16% oamputations 6 2 51% 12.4% complication 5.6% mortality

vascular trauma
PROGNOSTIC FACTORS FOR LIMB SALVAGE

time mechanism anatomic location associated injuries physiologic health clinical presentation

SEQUENCE

history clinical noninvasive intraop invasive postop invasive

vascular trauma
MOLECULAR BIOLOGIC MILLEU

free radicals neutrophils degraded arachidonic acids

RENAL LIVER CARDIAC LUNGS

posterior knee dislocation

30%-60% popliteal arterial injury

20%-50% amputation rate

Frykberg, Surg Clin N A 2002;82:67-89

vascular trauma
SOFT SIGNS
NEUROLOGIC deficit LIMITED hematoma HISTORY OF hemorrhage CONTRALATERAL strong pulses

vascular trauma
HARD SIGNS
ABSENT pulses BRUIT/thrill PULSATILE hematoma ACTIVE hemorrhage DISTAL ischaemia pain pallor paralysis paraesthesia poikilothermia

vascular trauma
MANAGEMENT PRIORITIES life threathening associated injuries extremity reperfusion skeletal stabilization soft tissue: debridement hemostasis nerve & tendon irrigation wound coverage

skeletal-vascular trauma
RATIONALE

PRIORITIES

perfusion is sine qua non minimizes delay to maximize salvage mostly negligible incidence (of initial vascular disruption)

LIMB

SURVIVAL/FUNCTIONS

combined vascular-skeletal trauma 19 amputations skeletal 60% vascular 9% 35 amputations skeletal 36.5% vascular 16.6%
J Trauma 1983;23:279 J Cardiovasc Surg 1979;20:473

combined vascular-skeletal trauma interval to revascularization skeletal 273 minutes vascular 137 minutes

J Trauma 2003;54:211

combined efforts
REPERFUSION CONSIDERATONS

exposure for proximal and distal control vessel debridement distal thrombectomy distal heparin flush RESTORE FUNCTION intraluminary shunt vascular repair FASCIOTOMY completion arteriography full thickness tissue coverage

Ruptur a.Femoralis Superfisial I

Repair & Graft

PascaPasca -repair & graft

Infeksi pasca iskemia

Thomas J. Fogarty

1963