Vascular Emergencies

VASCULAR VASCULAR EMERGENCIESEMERGENCIESSTEVE HENAO MDSTEVE HENAO MDVascular Surgery & Vascular Interventional Vascular Surgery & Vascular Interventional RadiologyRadiology

New Mexico Heart InstituteNew Mexico Heart Institute

STEVE HENAO MDSTEVE HENAO MD

ACUTE LIMB ACUTE LIMB ISCHEMIAISCHEMIA

SUDDENSUDDEN DETERIORATION OF THE ARTERIAL DETERIORATION OF THE ARTERIAL SUPPLY SUPPLY

CAUSESCAUSES

TRAUMATRAUMA

IATROGENICIATROGENIC

EMBOLISMEMBOLISM

THROMBOSISTHROMBOSIS

STEVE HENAO MDSTEVE HENAO MD

EMBOLISMEMBOLISM

from the Greek from the Greek embolosembolos, , or “plug”or “plug”

usually occurs in otherwise normal arteriesusually occurs in otherwise normal arteries

STEVE HENAO MDSTEVE HENAO MD

ThrombosisThrombosis

““blood clotting within an artery”blood clotting within an artery”

progressiveprogressive atherosclerotic obstruction atherosclerotic obstruction

hypercoagulabilityhypercoagulability

aortic or arterial dissectionaortic or arterial dissection

STEVE HENAO MDSTEVE HENAO MD

Clinical PresentationClinical Presentation

acute ischemia affects acute ischemia affects sensorysensory nerves first nerves first

motormotor nerves nerves

skinskin

muscle tissuemuscle tissue

muscle tenderness is one of the end-stage muscle tenderness is one of the end-stage signssigns

STEVE HENAO MDSTEVE HENAO MD

historyhistory

DURATION OF SYMPTOMSDURATION OF SYMPTOMS IS THE MOST IS THE MOST IMPORTANT PART OF THE HXIMPORTANT PART OF THE HX

irreversible muscle necrosis in irreversible muscle necrosis in 6 - 8 hours6 - 8 hours

STEVE HENAO MDSTEVE HENAO MD

physicalphysical

““P’sP’s””

pain, pallor, paresis, pulse deficit, pain, pallor, paresis, pulse deficit, paresthesia, poikilothermyparesthesia, poikilothermy

STEVE HENAO MDSTEVE HENAO MD

Initial managementInitial management

immediate anticoagulation with immediate anticoagulation with heparinheparin

leg stabilizationleg stabilization

prevent deteriorationprevent deterioration

O2O2 by facemask by facemask

improve skin perfusionimprove skin perfusion

IVFIVF resucitation resucitation

catheter monitoring for urine outputcatheter monitoring for urine output

analgesiaanalgesia

STEVE HENAO MDSTEVE HENAO MD

VASCULAR TRAUMAVASCULAR TRAUMA- head and neck- head and neck

Penetrating injuriesPenetrating injuries

80% of deaths are 80% of deaths are strokestroke related related

STEVE HENAO MDSTEVE HENAO MD

Clinical presentationClinical presentation

Neck classically divided into Neck classically divided into “zones”“zones”

IIIIII: above the angle of the : above the angle of the mandiblemandible

IIII: between cricoid and : between cricoid and mandiblemandible

most common (47%)most common (47%)

II: below cricoid: below cricoid

STEVE HENAO MDSTEVE HENAO MD

evaluationevaluation

Hard signsHard signs: : 97% have a vascular injury97% have a vascular injury

shock, refractory hypotension, pulsatile shock, refractory hypotension, pulsatile bleeding, bruit, enlarging hematoma, loss bleeding, bruit, enlarging hematoma, loss of pulse with stable or evolving of pulse with stable or evolving neurologic deficitneurologic deficit

Soft signs: Soft signs: only 3% have a vascular injuryonly 3% have a vascular injury

hx of bleeding at scene, stable hx of bleeding at scene, stable hematoma, nerve injury, proximity of the hematoma, nerve injury, proximity of the injury track, unequal arm BPsinjury track, unequal arm BPs

STEVE HENAO MDSTEVE HENAO MD

STEVE HENAO MDSTEVE HENAO MD

BCVIBCVI

““blunt cerebrovascular injury”blunt cerebrovascular injury”

less than 1% of all admissions for blunt traumaless than 1% of all admissions for blunt trauma

stroke rates range from 25 to 58%stroke rates range from 25 to 58%

mortality rates 31 to 59%mortality rates 31 to 59%

many patients initially asymptomaticmany patients initially asymptomatic

can develop symptoms from 1 hr to many weekscan develop symptoms from 1 hr to many weeks

screeningscreening

STEVE HENAO MDSTEVE HENAO MD

BCVIBCVI

STEVE HENAO MDSTEVE HENAO MD

BCVIBCVI• 16 slice 16 slice CTACTA has been validated as the primary has been validated as the primary

screening modality for BCVIscreening modality for BCVI

STEVE HENAO MDSTEVE HENAO MD

BCVIBCVI• The mainstay of treatment for BCVI is The mainstay of treatment for BCVI is

antithrombotic therapyantithrombotic therapy

• If the patient has no contraindications to If the patient has no contraindications to anticoagulation, a prudent protocol would be anticoagulation, a prudent protocol would be heparin therapy (goal, activated partial heparin therapy (goal, activated partial thromboplastin time of 50 to 60 seconds) and thromboplastin time of 50 to 60 seconds) and transition to warfarin (goal, international transition to warfarin (goal, international normalized ratio of 2.0) for 3 months. normalized ratio of 2.0) for 3 months.

• Antiplatelet therapy should be used for the same Antiplatelet therapy should be used for the same period.period.

STEVE HENAO MDSTEVE HENAO MD

Subclavian InjurySubclavian Injury

• Injuries to the thoracic outlet are often lethal.Injuries to the thoracic outlet are often lethal. Prehospital mortality is 50% to 80%, and of Prehospital mortality is 50% to 80%, and of those patients who survive transport, 15% die those patients who survive transport, 15% die during treatment.during treatment.

• long-term morbidity may be secondary to long-term morbidity may be secondary to brachial plexus injuries.brachial plexus injuries.

• Endovascular treatmentEndovascular treatment in this area can in this area can obviate the need for extensive dissection at obviate the need for extensive dissection at the base of the neck.the base of the neck.

STEVE HENAO MDSTEVE HENAO MD

STEVE HENAO MDSTEVE HENAO MD

Cervical Venous InjuriesCervical Venous Injuries

• If the patient has hard signs of a vascular If the patient has hard signs of a vascular injury and is in extremis, injury and is in extremis, the neck and the neck and subclavian veins can be ligated with limited subclavian veins can be ligated with limited morbiditymorbidity..

• If the internal jugular vein is ligated, the If the internal jugular vein is ligated, the patient should be monitored for patient should be monitored for cerebral cerebral edemaedema; however, this is a rare occurrence, ; however, this is a rare occurrence, even with bilateral internal jugular vein even with bilateral internal jugular vein ligation.ligation.

STEVE HENAO MDSTEVE HENAO MD

VASCULAR TRAUMA:VASCULAR TRAUMA:thoracicthoracic

BLUNT AORTIC INJURYBLUNT AORTIC INJURY

80% caused by MVC80% caused by MVC

head-on collisions - most commonhead-on collisions - most common

pts young - mean age: 39pts young - mean age: 39

9% survival at scene/ 9% survival at scene/ 98% overall mortality98% overall mortality

substance abuse is a factor in 40%substance abuse is a factor in 40%

seat belt use decreases risk by a factor of 4seat belt use decreases risk by a factor of 4

ejection from vehicle doubles the riskejection from vehicle doubles the risk

STEVE HENAO MDSTEVE HENAO MD

BAIBAI

CXRCXR

subxiphoid ultrasoundsubxiphoid ultrasound

multi - slice CTAmulti - slice CTA

ONCE DIAGNOSIS IS MADE = IMMEDIATE ONCE DIAGNOSIS IS MADE = IMMEDIATE SURGERYSURGERY

STEVE HENAO MDSTEVE HENAO MD

VASCULAR TRAUMA:VASCULAR TRAUMA:abdominalabdominal

penetrating trauma responsible for 90% of penetrating trauma responsible for 90% of abdominal vascular injuriesabdominal vascular injuries

LOW VELOCITY: DIRECT INJURY TO VESSELLOW VELOCITY: DIRECT INJURY TO VESSEL

HIGH VELOCITY: SHOCK WAVE/TRANSIENT HIGH VELOCITY: SHOCK WAVE/TRANSIENT CAVITATIONCAVITATION

STEVE HENAO MDSTEVE HENAO MD

blunt abdominal traumablunt abdominal trauma

rapid deceleration (MVC, falls)rapid deceleration (MVC, falls)

direct AP crushing (seat belt, direct blows)direct AP crushing (seat belt, direct blows)

direct laceration by bone fragment (severe direct laceration by bone fragment (severe pelvic fx)pelvic fx)

STEVE HENAO MDSTEVE HENAO MD

STEVE HENAO MDSTEVE HENAO MD

common vessels injuredcommon vessels injured

IVC : 25%IVC : 25%

Aorta : 21%Aorta : 21%

Iliac arteries : 20%Iliac arteries : 20%

Iliac veins : 17%Iliac veins : 17%

superior mesenteric vein :11%superior mesenteric vein :11%

superior mesenteric artery : 10%superior mesenteric artery : 10%

STEVE HENAO MDSTEVE HENAO MD

Prehospital treatmentPrehospital treatment

Rapid transportation to Trauma CenterRapid transportation to Trauma Center

““SCOOP AND RUN”SCOOP AND RUN”

‘‘CONTROLLED HYPOTENSIONCONTROLLED HYPOTENSION’’

trying to balance exanguination against trying to balance exanguination against cardiac arrestcardiac arrest

Immediate surgical control of the bleedingImmediate surgical control of the bleeding

STEVE HENAO MDSTEVE HENAO MD

• Computed tomography (CT) has little or no role Computed tomography (CT) has little or no role in suspected vascular injuries resulting from in suspected vascular injuries resulting from penetrating traumapenetrating trauma during the acute stage. during the acute stage. However, it may play a useful role in blunt However, it may play a useful role in blunt trauma by identifying large hematomas, false trauma by identifying large hematomas, false aneurysms, or vessel occlusionsaneurysms, or vessel occlusions

STEVE HENAO MDSTEVE HENAO MD

STEVE HENAO MDSTEVE HENAO MD

STEVE HENAO MDSTEVE HENAO MD

STEVE HENAO MDSTEVE HENAO MD

VASCULAR TRAUMA:VASCULAR TRAUMA:extremityextremity

90% of all peripheral arterial injuries occur in 90% of all peripheral arterial injuries occur in an extremityan extremity

civilian: upper extremitiescivilian: upper extremities

military: lower extremitiesmilitary: lower extremities

STEVE HENAO MDSTEVE HENAO MD

evaluationevaluation

Hard signsHard signs: (IMMEDIATE SURGICAL : (IMMEDIATE SURGICAL EXPLORATION)EXPLORATION)

observed pulsatile bleeding, arterial observed pulsatile bleeding, arterial thrill, bruit, absent distal pulse, visible thrill, bruit, absent distal pulse, visible expanding hematomaexpanding hematoma

Soft signs: Soft signs:

hemorrhage by history, neurologic hemorrhage by history, neurologic abnormality, diminished pulse, proximity abnormality, diminished pulse, proximity to bone injury or penetrating woundto bone injury or penetrating wound

STEVE HENAO MDSTEVE HENAO MD

intra-arterial drug intra-arterial drug injectioninjection

often neglected, often neglected, frequently misdiagnosed and mistreated arterial frequently misdiagnosed and mistreated arterial injuryinjury

BRACHIAL ARTERY : most commonBRACHIAL ARTERY : most common

street drugs w/ insoluble additivesstreet drugs w/ insoluble additives

SITE OF INJECTION SHOULD BE LOCATED AND NOTEDSITE OF INJECTION SHOULD BE LOCATED AND NOTED

injection followed by severe, unremitting paininjection followed by severe, unremitting pain

accompanied by edema, numbness, discoloration, cyanosis, accompanied by edema, numbness, discoloration, cyanosis, mottlingmottling

STEVE HENAO MDSTEVE HENAO MD

QUESTIONS?QUESTIONS?

INTERESTING STORIES?INTERESTING STORIES?

VASCULAR VASCULAR EMERGENCIESEMERGENCIESSTEVE HENAO MDSTEVE HENAO MDVascular Surgery & Vascular Interventional Vascular Surgery & Vascular Interventional RadiologyRadiology

New Mexico Heart InstituteNew Mexico Heart Institute