VASCULAR SURGICAL EMERGENCIES, REPERFUSION EFFECTS, COMPARTMENT SYNDROME, INTRA ARTERIAL INJECTION, FOR EMERGENCY MEDICINE TRAINEES

1. EMERGENCIES IN VASCULAR
SURGERY
Dr. JoelArudchelvam
ConsultantVascular andTransplant Surgeon
Teaching HospitalAnuradhapura

2. Some Vascular Emergencies
 Acute limb Ischaemia
 Accidental arterial injection
 Compartment syndrome
 Vascular trauma
 Deep vein thrombosis

3. Acute limb Ischaemia
 Sudden interruption of blood supply to
limb resulting in threat to the limb
viability.

4. Acute limb Ischaemia

5. Acute limb Ischaemia
Presentation
“ P ”s
 Pain
 pallor
 Perishing cold
 Pulselessness
 Paresis / paralysis
 Paraesthesia / anaesthesia.
Beware
 After trauma
 After anaesthesia
Diagnosis – Clinical
 “do not waste time on investigation”

6. 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)
 Refer to vascular surgeon
 Pain relief
 Keep fasting
 Check theViability of the limb - note.
 Acute limb ischemia is a clinical diagnosis -there
is no need of imaging.

7. Acute limb Ischaemia
 Surgery
 Embolectomy with
fogarty catheter
 Can be done under LA
 Post op
 Monitor distal pulse
 Continue heparin
 Start warfarin
 Monitor for
reperfusion effects

8. Reperfusion effects
 Local
 Reperfusion injury – paradoxical death of already
dying muscles after reperfusion
 Systemic
 Reperfusion syndrome
 Hypotension
 ARDS
 Lactic acidosis
 Hyperkalemia
 Renal failure

9. Reperfusion effects
 Local
 Reperfusion injury – paradoxical death of already
dying muscles after reperfusion

10. DURING ISCHAEMIA

11. DURING ISCHAEMIA

12. AFTER REPERFUSION

13. AFTER REPERFUSION

14. MANAGEMENT OF REPERFUSION EFFECTS

15. MANAGEMENT OF REPERFUSION EFFECTS

16. Reperfusion effects
 Systemic
 Substances Released
 Lactic Acid
 K+
 Inflammatory Mediators
 Myoglobin
 Activated Leucocytes
 Etc.

17. Reperfusion effects
 Systemic
 Reperfusion syndrome
 Hypotension
 ARDS
 Lactic acidosis
 Hyperkalemia
 Renal failure

18. Reperfusion effects
 Mangement
 Ligation of vessel if not responding to other
supportive measures

19. Compartment syndrome
Reduced organ perfusion due to increased
intra compartment pressure.
 Compartment Perfusion Pressure (CPP)
 MeanArterial Pressure (MAP)
 Intra Compartmental Pressure (ICP)
CPP = MAP – ICP

20. Compartment syndrome
Causes
 Trauma (muscle contusion)
 Haematoma
 Reperfusion
 Intracompartmental extravasation of fluids
 Tight bandage, cast

21. Compartment syndrome
Clinical features
 Excessive pain - pain on passive movements
 Numbness -e.g. anterior compartment first toe web
(deep peroneal nerve )
 Tense swollen leg
 Do not look for absent distal pulse – late

22. Compartment syndrome
Treatment
 Recognize
 Remove the cause
 Reduce intracomparmental pressure
 Remove bandages and cast
 Fasciotomy

23. Compartment syndrome
Treatment

24. Compartment Syndrome
Fasciotomy

25. Accidental intra-arterial
injection
 Problems
 Haematoma / false aneurysm
 Ischaemia
 Due to arterial dissection and thrombosis
 Due to the effects of the drugs

26. Accidental intra-arterial injection
Drugs causing ischaemia / necrosis
Hyperosmolar Acids/alkalis Vasoconstrictors
Calcium chloride Aminophylline Epinephrine
Calcium gluconate Amiodarone Dobutamine
Magnesium sulphate Amphotericin Dopamine
Parenteral nutrition Diazepam Metaraminol
Potassium chloride Phenytoin Norepinephrine
Sodium bicarbonate Thiopental
Vasopressin
Vancomycin

27. Pathophysiology
 Arterial Spasm
 Chemical Arteritis
 Crystal Formation

28. Accidental intra-arterial
injection
Recognition
 Flashback -pulsatile.
 Flashback blood redder than usual.
 Haematoma formation
 severe discomfort distal to the site
of injection
 Signs of distal ischemia
 Pain
 Pale /cyanosis
 Perishing Cold
 Absent pulse
 Paresthesia / anaesthesia
 Paresis / Paralysis

29. Accidental intra-arterial
injection
Management
 Stop the injection
 Leave the cannula in place
 Vascular surgical referral
 Anticoagulation – heparin 75U/ Kg stat and 18
U/ Kg hourly
 Inject lidocaine, papaverine through cannula

30. Accidental intra-arterial
injection
Management cont…
 Calcium channel blockers
 Aspirin, Methylprednisolone –Thromboxane
blocker
 Iloprost - Prostacycline analogue
 Stellate ganglion block - vasodilatation
 Analgesia

31. Vascular trauma / injuries
Causes
 RoadTraffic injuries – 60%
 Trap Gun
 Iatrogenic - 25%
 Penetrating / Sharp
 Blunt

32. Mechanism of disruption of flow
at arterial level
 Transection
 Laceration
 Contusion
 Kink
 Intimal flap

33. Vascular trauma
Signs 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

34. Vascular trauma
 Soft signs
 Reduced pulse
 Hematoma
 Injury close to a known neurovascular bundle
 paresis/ paralysis and paresthesia / anaesthesia - late
signs
 Paresis and paresthesia - viability in immediate threat
 Anaethesia and paralysis -not viable.

35. Investigations
Investigations
• Hard signs
• urgent intervention
• Soft signs
• Observe
• Investigate

36. Investigations
• Hand held Doppler
• Absent Doppler flow
• Quality of signal
• Duplex scan (USS +
Doppler )
• Difficult to image in trauma
• Due to
• Pain
• Non cooperative patient
• Dressings

37. Investigations
 Angiography
 CT angiography
 Catheter angiography

38. CT ANGIOGRAPHY

39. TREATMENT
Surgical Repair
 Prompt transport to operating room
 Entire limb cleaned should be able to palpate distal pulses.
 Thigh prepared – for venous harvest
 Mobilisation and control of proximal and distal arterial ends
and trimming

40. Surgical repair (cont..)
 Balloon thrombectomy
 Systemic and distal heparinisation
 Interposition graft / Direct
approximation
 Unit experience – 88.2% RSVG
 Prosthesis
 lower patency
 infection

41. Surgical repair (cont..)

42. POST OPERATIVE MONITORING
 Monitor distal pulse / Sao2
 Keep limb elevated
 Check movement and sensation
 Follow surgical instruction regarding
anticoagulation
 Look for compartment syndrome
 Look for post perfusion effects
 Do not apply encircling dressings

43. Deep Vein Thrombosis
 Thrombosis – formation of solid material
within the circulation using blood
components.
 Phlebothrombosis
 Thrombophlebitis

44. DVT Causes - Virchows triad

45. Clinical presentation
 Leg swelling
 Pain

46. Investigations
 D dimer
 Originate from clot lysis
 Duplex scan ( USS +
Doppler)
 Solid material inside vessel
 Non compressible
 Absent flow

47. Diagnosis and treatment

48. Diagnosis and treatment
 LMWH (low molecular weight heparin) – e.g. Enoxaparin
(1 mg/kg twice daily SC), dalteparin, tinzaparin
 Advantages
 does not require infusion
 Does not need frequent monitoring
 Unfractionated Heparin
o Loading dose 75 – 100 IU/Kg ( approx 5000 IU )
o Followed by Infusion of heparin -18U/kg (approx -
1000U/hr )
o monitored with APTT. (Keep APTT between 60 to 80s)

49. Diagnosis and treatment
 Also Start
o Warfarin
o10 mg D1
o10 mg D2
o5 mg D3
 Target INR - between 2 – 3
 When INR between 2 - 3 for 2 days omit heparin.
 Continue warfarin for 3 months

50. Diagnosis and treatment
 Other measures
 Analgesics
 Compression stocking
 Foot end elevation
 Hydration
 Young recurrent DVT – haematology referral

51. Pulmonary embolism
 PE occurs in 60 to 80% of patients with DVT
 Only half are symptomatic
 4% massive PE, Mortality – 60%

52. Pulmonary embolism
 Clinical features depends on the size of the embolus
 Small – lodges at peripheral pulm.Vessels
 Pain (pleuritic), effusion
 Larger – at branching points
 Wedge shaped infarction
 Pleuritic pain,effusion, tachypnoea
 Massive – occludes the bifurcation
 Sudden onset pain
 SOB
 Haemodynamic instability

53. Pulmonary embolism
 Diagnosis
 Gold standard – CT pulmonary angiogram

54. Pulmonary embolism
 Other tests
 Arterial Blood Gases
 Hypoxemia
 Hypocapnia
 Alkalosis
 ECG – only 20% has classic changes
 S1 Q3 T3
 Right heart strain
 Tall P waves in lead II (P pulmonale),
R axis deviation, RBBB
 2D ECHO – R heart strain

56. Vascular emergencies
 Look for / monitor
 Recognize
 Refer

57. Thank You