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VASCULAR TRAUMA

W. Binafsihi
RSPAD
Gatot Soebroto
Jakarta
combined
vascular-skeletal
trauma
0.2% of all trauma
10%-15% blunt limb vascular trauma
0.3%-3% limb arterial injury of all FXs
10%-70% amputation rate

Howe, Am Surg 1987;53-205


Attebery, J A C S 1996;183:377
89MF/10yrs rural 10.000sqmiles

Traffic 33% 34% arteriography


13 1 oamputations
Farm/Industrial 16%
6 2 oamputations
Gun, knives etc 51%
Kolvunen D
Nichols K
12.4% complication
Silver D 5.6% mortality
University of Missouri
Health Sciences Center
U.S.A.

Surgery 1982; 91(6):723-727


vascular trauma
PROGNOSTIC FACTORS FOR LIMB SALVAGE

time
mechanism
anatomic location
associated injuries
physiologic health
clinical presentation
SEQUENCE

history
clinical
noninvasive
intraop invasive
postop invasive
vascular trauma
MOLECULAR BIOLOGIC MILLEU
free radicals
neutrophils
degraded arachidonic acids
RENAL
LIVER
CARDIAC
LUNGS
posterior knee dislocation

30%-60% popliteal arterial injury

20%-50% amputation rate

Frykberg, Surg Clin N A 2002;82:67-89


vascular trauma
SOFT SIGNS

NEUROLOGIC deficit
LIMITED hematoma
HISTORY OF hemorrhage
CONTRALATERAL strong pulses
vascular trauma
HARD SIGNS
ABSENT pulses
BRUIT/thrill
PULSATILE hematoma
ACTIVE hemorrhage
DISTAL ischaemia pain
pallor
paralysis
paraesthesia
poikilothermia
vascular trauma
MANAGEMENT PRIORITIES
life threathening associated injuries
extremity reperfusion
skeletal stabilization
soft tissue: debridement
hemostasis
nerve & tendon
irrigation
wound coverage
skeletal-vascular trauma
RATIONALE PRIORITIES
perfusion is sine qua non
minimizes delay to maximize salvage
mostly negligible incidence
(of initial vascular disruption)

LIMB SURVIVAL/FUNCTIONS
combined vascular-skeletal trauma

19 amputations skeletal 60%


vascular 9%

35 amputations skeletal 36.5%


vascular 16.6%
J Trauma 1983;23:279
J Cardiovasc Surg 1979;20:473
combined vascular-skeletal trauma

interval to revascularization
skeletal 273 minutes
vascular 137 minutes

J Trauma 2003;54:211
combined efforts
REPERFUSION CONSIDERATONS
exposure for proximal and distal control
vessel debridement
distal thrombectomy
distal heparin flush
RESTORE FUNCTION intraluminary shunt
vascular repair
FASCIOTOMY
completion arteriography
full thickness tissue coverage
Ruptur a.Femoralis Superfisial I
Repair & Graft
Pasca--repair & graft
Pasca
Infeksi pasca iskemia
Thomas J. Fogarty

1963