Dr. Joel Arudchelvam Consultant Vascular and transplant surgeon

Teaching Hospital Anuradhapura

Pre intern training programme Nov 2015 Teaching Hospital Jaffna.

Some Vascular Emergencies

Acute limb Ischaemia

Vascular trauma

compartment syndrome

Acute limb Ischaemia

Sudden interruption of blood supply to limb resulting in threat to the limb viability.

Acute limb Ischaemia

Inside the vessel Embolus

on the wall of vessel ThrombosisTraumaDissection

Compression from outsideTight bandage, cast, tourniquetCompartment syndromeBurn

Acute limb Ischaemia

Inside the vessel Embolus

on the wall of vessel ThrombosisTraumaDissection

Compression from outsideTight bandage, cast, tourniquetCompartment syndromeBurn

Acute limb Ischaemia

Patient presentation With evidence of ischaemia (P’s)

pain - which is severe and sudden onsetpallorPerishing coldPulselessnessParesis / paralysisParaesthesia / anaesthesia.

Acute limb Ischaemia

Management

Recognize Start unfractionated heparin

Loading dose 75 – 100 IU/Kg ( approximately 5000 IU ) Followed Infusion of heparin -18U/kg (approximately -1000U/hr)

Pain reliefKeep fasting Check the Viability of the limb - note.Acute limb ischemia is a clinical diagnosis -there is no

need of imaging.Arrange transfer (after discussing/fasciotomy)

Acute limb Ischaemia

Interventions:-

Embolectomy – using balloon tipped Fogarty catheter + /- Fasciotomy Continue heparin (infusion 18U/kg) until the INR is 2-3

for 2 days Start warfarin – adjust dose to keep INR between 2-3 Monitor distal pulse and for effects of reperfusion

Vascular traumaSigns of a vessel injury Hard signs

Active bleeding Thrills, Bruits Signs of distal ischemia

Absent pulse Pain Pale Perishing Cold Paresthesia / anaesthesia Paresis / Paralysis

Expanding hematoma

Soft signs Hematoma Injury close to a known neurovascular bundle

paresis/ paralysis and paresthesia / anaesthesia - late signs Paresis and paresthesia - viability of the limb is in immediate threat anaethesia and paralysis -not viable.

Vascular trauma

Management

Patients with vascular injury often have associated injuries

–resuscitation

If patient has hard signs – no need of imaging - send to

OT immediately/ transfer after discussing.

Soft signs - monitor

Compartment syndrome

Reduced organ perfusion due to increased intra compartment pressure.

Causes;Trauma (muscle contusion)HaematomaReperfusion Intracompartmental extravasation of fluidsTight bandage, cast

Compartment syndrome

Clinical features

Excessive pain - pain on passive movements of the muscles.

Numbness -e.g. anterior compartment results in numbness at first toe web i.e. deep peroneal nerve distribution)

Tense swollen compartment

Compartment syndromeTreatment

Recognize

Remove the cause

Surgery – fasciotomy

Thank You