Vascular Trauma

Vascular Trauma - Bleeding Battleground

Damage to arteries or veins, often life/limb-threatening.

• Mechanisms:
  • Penetrating: Gunshot wounds (GSW), stab wounds.
  • Blunt: Fractures, dislocations, crush.
  • Iatrogenic: Post-procedural.
• Hard Signs (➡️ OR):
  • Pulsatile bleeding, expanding hematoma.
  • Absent distal pulses, palpable thrill, audible bruit.
  • Signs of acute limb ischemia (📌 6 P's: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia).
• Soft Signs (➡️ Investigate):
  • Hx of arterial bleed, diminished pulses, injury near artery (fracture/dislocation), nerve deficit.
• Diagnosis: ABI <0.9, CT Angiography (CTA), Duplex USG.
• Management: ABCDEs, direct pressure, tourniquet. Definitive: Surgical (repair/bypass), Endovascular.

⭐ Most common mechanism of major vascular injury is penetrating trauma (e.g., GSW, stab wounds).

Diagnosis - Spot the Leak

• Clinical Evaluation: Assess for hard and soft signs of vascular injury.

  Hard Signs (Immediate OR) 📌 "PULSE B H"	Soft Signs (Further Investigation)
  Pulsatile bleeding	Small, stable hematoma
  Unexplained shock/hypotension	Associated nerve injury
  Large/expanding hematoma	History of moderate hemorrhage (scene)
  Signs of ischemia (6 Ps)	Proximity to major vessel / Penetrating injury path
  Audible Bruit	Significant bony injury / Dislocation
  Palpable Thrill	Diminished (but palpable) pulses
  History of hemorrhage (active/pulsatile)

• Key Diagnostic Tools:
  • Ankle-Brachial Index (ABI): $ABI = P_{ankle} / P_{brachial}$. ABI < 0.9 suggests arterial injury.
  • Duplex Ultrasonography (DUS): Non-invasive, real-time, bedside assessment.
  • CT Angiography (CTA): Preferred modality for hemodynamically stable patients.
  • Conventional Angiography: Gold standard, especially if endovascular intervention is planned.

⭐ CT Angiography (CTA) is the diagnostic modality of choice for hemodynamically stable patients with suspected extremity vascular trauma.

Management - Stop the Flood

• Pre-Hospital & ED Resuscitation:

  • Direct pressure; tourniquet for severe limb bleed (note time). 📌 Convert <2h if possible.
  • ABCDEs, O2, 2 large-bore IVs.
  • Fluids: Crystalloids, then 1:1:1 blood products (PRBC:FFP:Platelets).
  • Permissive Hypotension: SBP 80-90 mmHg (penetrating), <110 mmHg (blunt) until control (not for TBI).
  • Reverse anticoagulants; give antibiotics, tetanus toxoid.

• Hemorrhage Control & Repair Strategy:

• Key Repair Principles & Adjuncts:
  • Obtain proximal/distal control.
  • Techniques: Primary suture, end-to-end anastomosis, vein graft (GSV preferred), ligation (damage control), endovascular (stents/embolization).
  • Fasciotomy: For compartment syndrome risk (ischemia >4-6h, combined A+V injury, swelling).

⭐ Popliteal artery injury with knee dislocation: high amputation risk (30-50% if repair >8h delayed), needs urgent surgery.

Complications - Aftermath & Alerts

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High‑Yield Points - ⚡ Biggest Takeaways

• Hard signs of vascular injury (e.g., pulsatile bleed, expanding hematoma, absent pulse, thrill/bruit) mandate immediate surgical exploration.
• Soft signs (e.g., history of bleed, diminished pulse, proximity, nerve deficit) warrant further investigation, typically CTA or Doppler USG.
• An Ankle-Brachial Index (ABI) < 0.9 strongly indicates significant arterial injury.
• The superficial femoral artery is the most commonly injured peripheral vessel.
• Compartment syndrome is a critical, limb-threatening complication requiring prompt fasciotomy.
• Temporary vascular shunting is vital in damage control surgery for complex injuries.
• Ligation is a life-saving option for non-critical arteries or in exsanguinating patients during damage control resuscitation (DCR).