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VASCULAR INJURY

Paul Tahalele Chief of The Department of Surgery School of Medicine Airlangga University Dr. Soetomo Teaching Hospital Surabaya, Indonesia

PIT IKABI XV, Jkt, 13-16 Juli 05

VASCULAR TRAUMA :

SYSTEMIC, REGIONAL, AND LOCAL


PATHOPHYSIOLOGIC PERTURBATION

Systemic effects : blood loss shock Local & Regional effects : mechanism of injury type of vessels injury

Gunshot: massive softy tissue injury collateral circulation disruption Blunt trauma: vessel wall contusion & intima disruption

TYPES of VESSELS INJURY

Mostly: laceration or transection Incomplete transection (Mattox 2000): Mild: <25% Moderate: 25-50% Severe: >50%

PROBLEM: REGIONAL ISCHEMIA Oxygen delivery Metabolic need


The vulnerability of a tissue to ischemia depends on the basal energy requirements & metabolic substrate stores (Mattox 2000)

PERIPHERAL NERVES: EXTREMELY VULNERABLE


High basal energy requirements No glycogen stores Short periode of ishemic neural damage Neuropathic symptoms (paresthesia) Neuropathic sign ( loss of light touch sensation)

1st SIGN OF ARTERIAL INJURY

SKELETAL MUSCLE: RELATIVELY TOLERANT

Malan & Tattoni (1963): < 4 h : no histologic changes > 6 h : changes, could be reversed with reperfusion Sanderson et al (1975): after 6 h: significant histologic changes that not be reversed with reperfusion

Cambria et al (1991), Colburn et al (1992), Jerome et al (1993): Complete interuption of all arterial inflow (including collaterals) will result in ischemic damage after 3 hours that can be extended (rather than reversed) by reperfusion

REPERFUSION INJURY

REPERFUSION INJURY

Generation of SUPEROXIDE ANION Vasoconstriction & Capillaries occlusion NO REFLOW PHENOMENON LIPID PEROXIDATION

Platelet agregation Microvascular obstruction (neutrophil activation)

DELAY : increase the risk of irreversible ischemic injury, organ failure, and death EARLY RECOGNITION AND TREATMENT GOAL: reperfusion of the ischemic limb within 6 hour or less

PROBLEMS

EARLY RECOGNITION / DIAGNOSIS QUICK MANAGEMENT


QUICK DIAGNOSIS QUICK OPERATION

LIMB SALVAGE OR AMPUTATION ? RECOGNITION OF TREATMENT FAILURE


(TIME, DIAGNOSTIC PROCEDURE)

MONEY, COST-EFFECTIVENESS

HARD SIGNS

Pulsatile bleeding Expanding hematoma Palpable thrill Audible bruit Evidence of regional ischemia:

Pallor Paresthesia Paralysis Pain Pulselessness Poikilothermia

SOFT SIGNS
History of moderate hemorrhage Injury (fracture, dislocation, or penetrating wound) in proximity to major artery Diminished but palpable pulse Peripheral nerve deficit

API
= ARTERIAL PRESSURE INDEX Systolic pressure on the injured limb Systolic pressure on the uninjured arm

API < 0.90


Sensitivity 95% Specificity 97% Negative predictive value 99%

(Johansen et al (1991))

AGRAM / ARTERIOGRAPHY
Negative predictive value 99-100% Sensitivity 97-100% Specificity 90-98% Accuracy 92-98%
(Mattox (2000))

(Mattox (2000))

B. Trauma Pembuluh Darah

Klasifikasi Perlukaan Arteri 1. Trauma langsung

( Vollmar, 1980 )

1.1 Trauma Tajam : a. Laserasi, luka tusuk, luka tembak b. Trauma iatrogenik ( tindakan angiografi, operasi, injeksi intra arteri ) 1.2 Trauma Tumpul :

Amputasi Traumatik

a. Kontusi ( Thrombosis ) b. Kompresi ( Hematoma, patah tulang ) c. Konstriksi ( Terjerat )


2. Trauma tidak langsung Replantasi 2.1. Spasma arteri; 2.2. Perlukaan arteri karena peregangan 2.3. Perlukaan arteri karena deselerasi ( aorto thoracalis ) 3. Cacad Kronis akibat Trauma Arteri 3.1. Thrombosis arteri 3.2. Aneurisma arteri 3.3. Fistula arteriovenous 3.4. Emboli

TRAUMA LANGSUNG

Trauma Tajam
Terdapat 2

jenis penyebab, yaitu :


tusuk, luka tembak

1. Laserasi, luka 2. Trauma

Iatrogenik ( tindakan angiografi,

operasi, injeksi intra arteri )

TRAUMA TUMPUL
Terdapat 3 jenis penyebab, yaitu : 1. Kontusi ( Thrombosis ) 2. Kompresi ( Hematoma, patah tulang )

3. Konstriksi ( Terjerat )
PITFALL 11 : Beberapa fraktur tulang panjang, dislokasi mayor atau luka penetrasi dapat menyebabkan trauma vaskular

Derajat arteri dan tanda klinis perlukaan tajam arteri


(Vollmar,1980)

Derajat kerusakan arteri dan tanda klinis trauma tumpul arteri (Vollmar,1980)

TRAUMA ARTERI TIDAK LANGSUNG


Spasma arteri Terapi spasma arteri : 1. Aplikasi lokal solusio 2,5 - 5% papaverine sulfate 2. Dilatasi mekanis dengan injeksi NaCl 0,9% intra arteri dengan tekanan atau baloon fogarty 3. Blok simpatis atau injeksi intra arteri obat anti spasmodik

Lokasi tersering dari trauma kompresi pada arteri karena fraktur supracondylar humerus dan femur atau hematoma pasca dislokasi sendi lutut (Vollmar, 1980)

Mekanisme perlukaan arteri karena peregangan sendi bahu

(Vollmar, 1980)

DIAGNOSIS TRAUMA ARTERI


Lima langkah utama dalam menegakkan diagnosis trauma aorta ( Adinolfi, et al., 1985; Vollmar, 1980 ) : 1. Anamnesa riwayat trauma : trauma tajam, tumpul, adakah penetrasi benda asing ? 2. Perdarahan : internal atau eksternal, bagaimana tanda klinis sistemik dan lokal ? 3. Tanda iskemik : warna kulit, suhu, pulsasi perifer, pengisian vena ? Hati-hati bila pada tungkai dengan akral dingin pada keadaan syok. 4. Pemeriksaan arteriografi bisa didahului ultrasonik doppler 5. Atau segera lakukan operasi eksplorasi Axioma2: Arteriografi umumnya tidak perlu jika operasi eksplorasi memberikan hasil yang nyata

Mekanisme perlukaan aorta karena deselerasi vertikal

Mekanisme perlukaan aorta karena deselerasi horizontal

Iskemik perifer, pertimbangkan adanya :


1. Kompresi arteri oleh fraktur, hematom fraktur atau konstriksi band sirkumferens 2. Spasma arteri ( keadaan yang jarang terjadi ) 3. Tanda-tanda sistemik seperti pada keadaan syok Setiap tindakan konservatif hanya terbatas sampai 3 - 4 jam,

bila tidak ada kemajuan perlu segera tentukan status vaskular


melalui saturasi perifer, ultrasonik doppler atau invasif

arteriografi atau tindakan operasi eksploratif ( Vollmar, 1980 )


PITFALL12: Jika diagnosis arteri tidak segera dibuat, sampai fungsi gerak menjadi lemah, maka terapi menjadi terlambat dan dapat mencelakakan

TATALAKSANA Pengobatan Trauma Arteri


Pengobatan trauma arteri ditujukan pada 2 hal: 1. Prevensi eksanguinasi akut dengan cara : kontrol
sumber perdarahan dan koreksi volume darah 2. Rekonstruksi segmen arteri yang rusak dan cegah terjadinya kerusakan jaringan karena iskemik

Kontrol sumber perdarahan: 1. Kompresi digital dengan jari-jari tangan pada bagian
proximal untuk arteri perifer 2. Bebat tekan aseptik pada tempat arteri yang terluka ( usahakan menghindari pemakaian torniquet ) 3. Untuk pembuluh darah besar seperti aorta dilakukan pengontrolan sumber perdarahan dengan cara kompresi digital langsung atau cara traksi memakai balloon kateter Fogarty atau menggunakan klem ataumatis

Cara kompresi digital, balloon kateter Fogarty dan klem atraumatis untuk mengontrol perdarahan pada aorta atau

arteri besar

Beberapa tehnik penjahitan untuk melakukan reparasi perlukaan arteri (a) dan cara penggunaan klem atraumatik (b)

MULTITRAUMA CASE
Senen / Male / 45 years old Time of Accident : February, 2nd 2005 (20.00) Mode of Injury : Traffic Accident Strucked by car from behind Revised Trauma Score : 7,8144

Diagnose : Rupture of right femoral artery at level proximal one third. Treatment : Performed laparotomy to control right extern iliac artery
Exploration: ruptured of proximal right femoral artery Performed: freshening, great saphenous graft.

RADIOLOGICAL EXAMINATION

Multitrauma Case

Sulikan/Male/52 years MOI : Traffic accident, motorcycle vs motorcycle T.o. Acc : 16.30 at January 30th 2005 Referred from : RS Islam Sakinah Mojokerto with the diagnosis is an abcess at right shoulder, and had been performed incision. After incisioning the mass, they found pus and cloth hematoma about 200 cc. RTS : 7,84

Diagnosis:
Pseudoaneurysme on right subclavian artery Right brachialis plexus lession Right one third lateral clavicle closed fracture Severe anemic

Planning:
Arteriography cito Blood transfusion

Arteriography: leakaged from right proximally subclavian artery, and formed pseudoaneurysme.

Obstruction of right subclavian and vertebralis artery

Interposition Graft

MULTITRAUMA CASE

Riska / Female /17 years old Time of Accident : February, 5th 2005 (13.30) Mode of Injury : Traffic Accident motorcycle struck by trailer Referred from Sidoarjo General Hospital and had been resuscitated with RL 4000 cc and WB 1 bag RTS : 3,3

DIAGNOSIS : Moderate head injury Hypovolemia shock Hypothermia Total Rupture of left femoral artery & vein, and partial ruptured of left common iliac vein. Pelvic fractured Right femur closed fractured TREATMENT : Laparotomy Reposition of fracture fragment & revision of c-clamp. ligature left femoral artery & vein and left common iliac vein
Px : Died

Pelvic X-ray

Chest X-ray

FAST : (+) morison pouch, perivesical

Operation

Multitrauma Case

Haryono/ Male / 23 years old MOI : Crush by iron plate ToAcc : 09.30 feb, 21th 2005 RTS :7,55

Diagnosis :

OF right femur grade IIIC OF left femur grade II

Ruptur a.femoral & trombus Treatment :

Fogarti & venograft from V.great saphena -- pulsation a. dorsum pedis + debridement + external fixation

FEMUR X-RAY

PELVIC X-RAY

THORAX X-RAY

ANGIOGRAFI (22/2/2005)

Multitrauma Case Report


Elis / Female / 21 years old ToAcc : June 20th, 2005 at 17.00 ToAd : June 20th , 2005 at 19.30 MOI : motorcycle rider hit by a truck RTS : 7.84 Patient : Pulang paksa

Diagnose : Vascular injury susp rupture of the left popliteal artery OF of the left tibial plateau gr III C CF of the left ankle Degloving of the left thigh until left leg
Treatment : Ortho : debridement + external fixation TCV : repair with graft great saphenous venous, interposition graft Ortho & Plastic : sirklase & viability test

June 23rd,2005

June 30th, 2005

Thank you