Acute arterial occlusion11 Feb 2009

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BackgroundCommon in ED

Embolus;

- MI

- mitral valve dis.

- AF

Thrombosis: chronic (skin change, muscle

atrophy)Schwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005

Diagnosis

History

Physical examination

- 6PS

- chronic arterial occlusion

Investigations

- doppler USG

- angiogram / CTASchwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005

HistoryAcute VS Chronic

Underlying disease: DM, HT, heart dis.

6Ps

TraumaRosen’s Emergency medicine concepts and clinical practice. 6 th ed. Philadelphia: Mosby; 2006

6PsPain

Pallor

Pulseless

Poikilothermia

Paresthesia

ParalysisSchwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005

Investigations

Color doppler USG

Angiography

- gold standard

- abnormal filling defect

CT angiogram

MRI / MRASchwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005

TreatmentOrgans / Limbs salvage: within 6 hours

Prevent complications

- compartment syndrome

- reperfusion injury Schwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005Sabiston textbook of surgery the biological basic of modern surgical practice. 18th ed. Philadelphia: Saunders; 2008

TreatmentGeneral

- Pain relief

- Pre-operative evaluation

- Correct metabolic imbalance

- Treat underlying dis. Schwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005Sabiston textbook of surgery the biological basic of modern surgical practice. 18th ed. Philadelphia: Saunders; 2008

TreatmentHeparinization (80/18)

- 80 units/Kg. IV bolus (5,000 units)

- 18 units/Kg/hr IV infusion

- Keep PT & INR 1.5 -2.5Schwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005Sabiston textbook of surgery the biological basic of modern surgical practice. 18th ed. Philadelphia: Saunders; 2008

TreatmentAll cases need pre-operative angiogram

Arterial exploration/endovascular technique

- forgathy embolectomy

- thrombectomy

- bypass graft

Vascular traumaCoincidence with others injury

- long bone fracture / dislocation

- penetration

Male (72-90%)

Peak 20-40 years old (90%)Schwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005Rosen’s Emergency medicine concepts and clinical practice. 6th ed. Philadelphia: Mosby; 2006

MechanismPenetration (70-90%)

Blunt trauma including blast injury

Iatrogenic injury esp. vascular intervention

Peripheral vascular injury. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill; 2008

“ Bleeding to shock or not

bleeding enough”

PathophysiologyCompleted occlusive injury

- Transection: bleeding or bloodless

- Thrombosis

- Reversible vasospasm

Peripheral vascular injury. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill; 2008

PathophysiologyNon-occlusive injury

- Intimal flap

- Pseudoaneurysm

- Arteriovenous fistula

- Compartment syndrome

Peripheral vascular injury. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill; 2008

Signs & Symptom

s6Ps

Association injury

Hard signs

Soft signs

Hard Signs Expanding / pulsatile hemaotma

Pulsatile bleeding

Palpable thrill

Audible bruit

Pulseless บาดเจ็�บหลอดเลอดแขนขา . ศั�ลยศัาสตร์�ฉุ�กเฉุ�น 2538Pitfalls and Management of Peripheral Vascular Injury. ศั�ลยศัาสตร์�วิ�วิ�ฒน� 26, 2544

Soft Signs Large non-expanding / non-pulsatile hemaotma

Isolated nerve injury

Diminish pulse

Prolong capillary refill

บาดเจ็�บหลอดเลอดแขนขา . ศั�ลยศัาสตร์�ฉุ�กเฉุ�น 2538Pitfalls and Management of Peripheral Vascular Injury. ศั�ลยศัาสตร์�วิ�วิ�ฒน� 26, 2544

Soft Signs Proximity to nerve bundle (< 1 cm.)

Trajectory crossed neurovascular bundle

Unidentified cause of shock

Long bone fracture and dislocation

บาดเจ็�บหลอดเลอดแขนขา . ศั�ลยศัาสตร์�ฉุ�กเฉุ�น 2538Pitfalls and Management of Peripheral Vascular Injury. ศั�ลยศัาสตร์�วิ�วิ�ฒน� 26, 2544

History Time of injury (< 6 hrs limbs salvage)

Mechanism of injury

- Penetration

- Crush

- Blunt

Factors affect wound healing

Physical examination ABCDE

Others association injury

6Ps

Neurologic examination

Pulse oximetry

Ankle Brachial Index (ABI)

Good collateral circulation

Congenital absence pulse

Generalize vasospasm

Pre-existing vascular disease

Mistakes

Pulse examinatio

n Compare both sides

Intensity: normal 2+

Palpate

Hand held doppler

Pulse examination

Pulse Right Dop Left Dop– Femoral + + ++ +

++– Popliteal - + + ++– Posterior tibial - + + +

+– Dorsalis pedis - + + +

+

Ankle Brachial Index (ABI) Screening test esp. soft signs

sBP ankle / sBP brachial

Ankle Brachial Index (ABI) Result

- 0.9-1.2 : normal

- 0.7-0.89 : mild arterial insufficiency

- 0.5-0.69 : moderate arterial insufficiency

- < 0.5 : severe arterial insufficiency

Schwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005Sabiston textbook of surgery the biological basic of modern surgical practice. 18th ed. Philadelphia: Saunders; 2008

Limitations of ABICan not evaluate venous injury

Can not detect deep artery injury

False positive in calcified vessels

Schwartz’s Principles of Surgery. 8th ed. New york: McGraw-Hill; 2005Sabiston textbook of surgery the biological basic of modern surgical practice. 18th ed. Philadelphia: Saunders; 2008

InvestigationsPlain X-rays: fracture / dislocation

Hand held doppler: arterial waveform

Color doppler USG: arterial blood flow

CTA / MRA

Arteriography: gold standard

AngiographyDecrease rate of negative vascular exploration

Indications

- Soft signs

- Multiple site injury

Pre-operative or intra-operative Peripheral vascular injury. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill; 2008

TreatmentOrgans / Limbs salvage: within 6 hours

Prevent complications

- compartment syndrome

- reperfusion injury

TreatmentGeneral

- ABCDE

- Initial resuscitation

- Stop bleeding

- Pre-operative evaluation

TreatmentMajor vascular injury

- treat within 6 hrs

- temporary vascular shunt

- vascular exploration and repair

- percutaneous embolization

- endovascular repairPeripheral vascular injury. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill; 2008บาดเจ็�บหลอดเลอดแขนขา . ศั�ลยศัาสตร์�ฉุ�กเฉุ�น 2538Pitfalls and Management of Peripheral Vascular Injury. ศั�ลยศัาสตร์�วิ�วิ�ฒน� 26, 2544

TreatmentVenous injury

- Mainly simple ligation

- Vascular exploration and repair

TreatmentMinor vascular injury

- Spontaneous stop (85%); intimal flap < 5 mm.,

pseudoaneurysm < 5 m. diameter

- Vascular exploration esp. child, active bleeding

- Simple ligationPeripheral vascular injury. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill; 2008บาดเจ็�บหลอดเลอดแขนขา . ศั�ลยศัาสตร์�ฉุ�กเฉุ�น 2538Pitfalls and Management of Peripheral Vascular Injury. ศั�ลยศัาสตร์�วิ�วิ�ฒน� 26, 2544

Peripheral vascular injury. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill; 2008

Conclusion

Common in ED

Careful history taking: Acute VS Chronic

Physical examination: Hard-soft signs, ABI

Limb salvage treatment

Thank you for your attention