VASCULAR INJURY

Arterial Bleeding Vs. Venous Bleeding Clinical Features

Arterial Venous Hard Signs20, 7:484 Soft Signs7:484
• High pressure • Low pressure • Observed pulsatile bleeding • Significant hemorrhage at the time of
• Bright red blood • Dark blood • Arterial thrill3:313 injury
• Expanding hematoma • Non-expanding hematoma1:992 • Bruit over or near the artery3:313 • Bony injury
• Shock • Shock is rare • Signs of distal ischemia (6Ps) • Penetrating wound or blunt trauma in
o Can be caused by massive bleeding • Visible expanding hematoma close proximity to a major artery
from pelvic bones or the inferior vena • Absent or diminished distal • Neurologic abnormality
cava1:992 pulses • Small non-pulsatile haematoma

• 40-50% of arterial injuries have concomitant venous injuries, specially in

the popliteal fossa1:992

Investigations3:313 Post-Operative
• X-ray • Close monitoring of vital signs
o Fractured bones • Distal pulses
o Dislocations • Distal saturation
• Arteriography • Continue anticoagulation5
o Should not delay vascular intervention • Look out for
o Compartment syndrome1:314
Treatment o Reperfusion injury1:421
• ATLS protocol 1:992
§ Rising creatinine levels
• External compression1:993 § Reduced urine output
• Intravenous heparin7:484 § SOB
o After excluding head injury and if patient does not have multiple
trauma7:643
• Associated fracture must be stabilized before the vascular repair8:314
o External fixator
• Viable limb + Ealry presentation: Vascular repair7:484,485
• Viable limb + Late presentation (Close to 6 hours or more): Fasciotomy +
Vascular repair7:484,485, 3:314
• Non-viable limb: Amputation3:314
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BURNS
You are the house officer at the Ampara General Hospital. You have gone home for a weekend after a long time, for a well deserved break. You’re at home
watching the your favourite TV programme when your neighbor rushes into the house saying that their 18 year old daughter has set hersekf on fire.

What are you going to do?

Pre-Hospital Care1:620, 19:232 Criteria for Hospital Admission1:620, 19:240

• Ensure rescuer safety • Extremes of age
• Stop burning process to reduce tissue damage (Stop, drop, roll) o < 5 years
• Remove patient from the site o > 60 years
• Suspected airway or inhalational injury1:617
o Smoke can cause injury to the airway
o Burns around the face and neck
• Check for other injuries o A history of being trapped in a burning room, car
o A quick ABC o Change in voice
• Remove burned/ hot clothes o Stridor
o Do not peel off if adhered to skin o Soot in the nose1:621
• Cool the burned wounds • Any burn needing IV fluid
o BSA >15%1:623 in adults > 10% in children1:623
o Running water in room temperature for a minimum of 10 minutes
• Any burn likely to require surgery
• Prevent hypothermia • BSA > 2% if full thickness burn
o Cover with warm, clean, dry linen • All electrical, chemical burns
• Elevation • Partial-thickness and full-thickness burn in the hand, face & neck, feet or
o Prop up in face burns perineum, over major joints
o Elevate affected limb to reduce oedema • Circumferential burn1:624
• Take the patient to the hospital as soon as possible o Form Eschar: TOURNIQUET EFFECT: RX: ESCHAROTOMY
• Psychiatric patient
• Non-accidental burn
• Pre-existing chronic illness
o Diabetes Mellitus
o IHD
o Epilepsy

Clinical Surgery
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Hospital Care

Primary Survey (ATLS)19:235-236 Secondary Survey19:237-238

• ATLS protocol • History19:233
• E: Exposure and environmental control19:232-233 o A: Allergies
o Remove clothing and jewellery o M: Medications
o Keep the patient warm o P: Past history
o Assess burn surface area: Wallace’s rule of nine o L: Last meal
o Assess depth o E: Event
o Examination of the burn: Colour, Pain, Capillary filling, Blisters • Examination: Head to toe
• Documentation

Assess Depth1:622, 20:667

Superficial Deep
Epidermal Superficial Partial Thickness Deep Partial Thickness Full Thickness Beyond Skin
• Sun burns • Hot water burns • Hot liquids, steam, • Flame, hot oil, steam • Flame
Eg:
grease, or flame
Degree I • II • II • III • IV
• Epidermis • Epidermal + Papillary • Up to reticular dermis • All layers of skin • Subcutaneous Fat
dermis • Hair follicles, and • All epidermal + dermal • Muscle
Depth • Deeper layers of the dermis, sweat and sebaceous structures are destroyed • Bone
hair follicles, and sweat and glands are burned
sebaceous glands are spared

Colour • Red • Red • Pale white/ yellow • Charred, pale and leathery • Charred
Blisters • No • Yes: HALLMARK • Yes/No • No • No
Capillary Refill/ Blanching • Yes • Yes • No: HALLMARK • No • No
Pain • Yes • Yes • No • No19:233 • No
• 1/52 • 2 - 3/52 • 3/52 – 2/12 • No spontaneous healing • No spontaneous
Healing
healing
• No scar • No/ minimal scar • Scar+ • Need skin graft20:667 • Life threatening
• Full return of function • Surgical debridement • Significant scar+ • Extensive
Prognosis and skin grafting reconstruction
MAY be necessary to • Amputation
obtain maximum
function
Clinical Surgery

Treatment

Initial19:237-239 Subsequent
• Weigh the patient • High calorie, high protein diet
• NG tube • Wound management
o Paralytic ileus: Shock can lead to ischaemia of the gut o Face and perineum
o Nutrition1:626 § Open
• IV cannulation19:233 § Povidone iodine
• Catheterize o Rest of the body
• Fluid resuscitation proportional to burned BSA § Closed
o Parkland Formula: 4ml X % BSA X weight § Silver sulfadiazine (SSD)1:630
o Crystalloid: Hartmann’s/ Hypertonic saline1:624 • Splint joints
§ 50% in the first 8hours • In neck burns: Cervical collar in extended position
§ 50% in next 16 hours • Physiotherapy1:627
o Colloid : Human Albumin Solution1:624 o Chest, limbs
• Monitoring • Psychological support1:627
o BP/PR/RR/SaO2, • Surgery
o UOP 0.5 - 1ml/kg/h: Best guide for fluid resuscitation o Escharotomy19:238
• Drugs § Limbs, neck, chest
o Analgesics o Skin graft1:629
§ IV Morphine, Pethidine, Fentanyl, Tramadol
AVOID IM as absorption is unpredictable1:626
o H2 receptor blockers: For stress ulcers
o Tetanus prophylaxis

When should SSD be avoided? 1:630

• Face: Leaves a black tattoo due to silver

• Pregnancy
• Nursing mothers
• Infants < 2months

Clinical Surgery

nd
On the 2 day patient becomes dyspnoic and you notice a reduction in UOP
despite adequate fluid resuscitation.

What are the possible causes?

Complications

• Renal: Acute tubular necrosis

o Hypovolaemia
o Myoglobinuria

• Cardio-Vascular
o Hypovolaemia
o DVT
o Acute bacterial endocarditis

• Pulmonary
o Inhalation injury1:618,621
o Respiratory failure
o ARDS
o Pneumonia

• Signs of impending airway obstruction1:620

§ Stridor/hoarseness
§ Black sputum
§ Facial burn
§ Facial oedema

• Gastrointestinal
o Ulcers in the stomach/duodenum: Curlings ulcer
o Paralytic ileus
o Acalculous cholecystitis

• Scarring

• Contractures

Clinical Surgery