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Vascular trauma

Mechanisms:

The commonest non-iatrogenic cause of injury to blood vessels in the UK is RTAs (usually blunt injuries)
Penetrating injuries (e.g. knife and gunshot wounds) are much less frequent
Iatrogenic injury to the brachial and common femoral arteries form angiography and angioplasty are by far the commonest examples
If the injury is caused by a sharp instrument, such as a knife, the arterial or venous wound tends to be limited to the area of immediate injury and the remaining vessel is uninjured
In some, particularly high-velocity, missile wounds or in blunt trauma, the extent of the injury is often more extensive, in terms of both the vascular injury and the associated injuries in other systems

Clinical features:

The 2 principle consequences of arterial injury are:

Haemorrhage:

Blood loss tends to be greater if there is only partial rather than complete transaction
This is because in partial transaction, the laceration is held open by the continuity part of the wall, whereas in complete transaction vasospasm and intimal retraction with thrombosis occur, which limits loss

Ischaemia:

This is often severe because the injury is acute and the vasculature has previously been normal; there has not been any opportunity for collaterals to become established

Physical findings:

In young people, provided that systolic BP is >100mmHg, peripheral pulses should be readily palpable
Absent or diminished pulsation should immediately alert the clinician to the likelihood of vascular injury
In a closed injury, an expanding haematoma may be palpable

Doppler examination:

An audible Doppler signal may be present from a collateral circulation even if the artery is transacted proximally
However, in the lower limb, if the ABPI does not equal that of the uninjured side, vascular injury should be suspected

Investigation:

Angiography should be considered in any instance where there is doubt about the diagnosis or where the site of injury is uncertain

Management:

Resuscitation
Immediate control of haemorrhage by direct pressure and then operation rapidly to restore flow are essential
The latter is achieved either by direct repair of the artery and accompanying large veins , if possible, or by means of a bypass graft
Because of the risk of infection, prosthetic materials should be avoided wherever possible
All patients who sustain vascular trauma should receive appropriate antibiotics and, when indicated, tetanus prophylaxis
The use if thromboembolic prophylaxis has to be decided on an individual basis and must balance the risks of thrombosis against those of haemorrhage
The risk of reperfusion injury is greatest in vascular trauma and fasciotomy is frequently indicated for prevention


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	Vascular trauma Mechanisms: The commonest non-iatrogenic cause of injury to blood vessels in the UK is RTAs (usually blunt injuries) Penetrating injuries (e.g. knife and gunshot wounds) are much less frequent Iatrogenic injury to the brachial and common femoral arteries form angiography and angioplasty are by far the commonest examples If the injury is caused by a sharp instrument, such as a knife, the arterial or venous wound tends to be limited to the area of immediate injury and the remaining vessel is uninjured In some, particularly high-velocity, missile wounds or in blunt trauma, the extent of the injury is often more extensive, in terms of both the vascular injury and the associated injuries in other systems Clinical features: The 2 principle consequences of arterial injury are: Haemorrhage: Blood loss tends to be greater if there is only partial rather than complete transaction This is because in partial transaction, the laceration is held open by the continuity part of the wall, whereas in complete transaction vasospasm and intimal retraction with thrombosis occur, which limits loss Ischaemia: This is often severe because the injury is acute and the vasculature has previously been normal; there has not been any opportunity for collaterals to become established Physical findings: In young people, provided that systolic BP is >100mmHg, peripheral pulses should be readily palpable Absent or diminished pulsation should immediately alert the clinician to the likelihood of vascular injury In a closed injury, an expanding haematoma may be palpable Doppler examination: An audible Doppler signal may be present from a collateral circulation even if the artery is transacted proximally However, in the lower limb, if the ABPI does not equal that of the uninjured side, vascular injury should be suspected Investigation: Angiography should be considered in any instance where there is doubt about the diagnosis or where the site of injury is uncertain Management: Resuscitation Immediate control of haemorrhage by direct pressure and then operation rapidly to restore flow are essential The latter is achieved either by direct repair of the artery and accompanying large veins , if possible, or by means of a bypass graft Because of the risk of infection, prosthetic materials should be avoided wherever possible All patients who sustain vascular trauma should receive appropriate antibiotics and, when indicated, tetanus prophylaxis The use if thromboembolic prophylaxis has to be decided on an individual basis and must balance the risks of thrombosis against those of haemorrhage The risk of reperfusion injury is greatest in vascular trauma and fasciotomy is frequently indicated for prevention
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