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the root of the neck. The dissection is taken above the level of the
bleeding and the site of the bleeding should become apparent and
more precisely directed pressure could be used to maintain control.
The assessment of the injury should be clear enough whether both the
artery and vein are involved. After adequate mobilization and proper
inspection of the injury, a decision can then be made whether repair can
be effected by direct suture of the vessel or reconstitution with a vein
patch of saphenous vein harvested from the thigh. Heparin, 60 IU kg,
should be given intravenously before applying vascular clamps to the
vessel.
If extensive repair is required with prolonged clamping of the common
carotid artery, the cerebral circulation could be maintained by inserting a
shunt.
II. UPPER LIMB.
a. The subclavian and axillary arteries.
Injury of the subclavian and axillary artery can result from high speed
road traffic accidents and especially if there is a fracture around the
shoulder or the first rib. The injury is presenting with an expanding
haematoma of the anterior chest wall extending into the axilla. The
pulse at the elbow is not palpable. In such cases prompt vascular
repair is indicated. Evacuation of haematomas around nerve trunks
could improve neurological outcome sometimes. Excision of the
damaged part with insertion of an interposition graft of saphenous
vein is usually required. Repair of axillary vein could usually be effected
by direct suture although vein patching may be needed. Injury of the
axillary artery could result from anterior dislocation of the shoulder
joint. Therefore pulses in the arm must always be checked after
successful reduction of the dislocation.
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b. The brachial artery.
This rare injury of the brachial artery may occur after humeral
fractures especially in midshaft fracture of the humerus. More common
is entrapment of the artery in supracondylar fracture in children with
the risk that a missed injury could result in Volkmann s ischemic
contracture. Therefore careful checking of the radial pulse following
reduction of the fracture is essential. In modern medical practice the
most common cause of brachial artery injury is arterial cannulation for
coronary angiography or angioplasty. Commonly resulting from
prolonged procedure and repeated several catheter changes. The case
is presented with a cold, pulseless hand. The development of paraesthesia
is an indication for urgent exploration. The repair is usually with a
vein patch.
On-table arteriography is helpful to check the distal circulation at the
end of reconstruction and evidence of occlusion is an indication for
thrombectomy.
c. Radial and ulnar artery damage.
Injury of these both arteries is rare and could be found in sever trauma
of the hand and forearm accompanied by extensive tendon and nerve
damage. Such cases require hand-surgical and microsurgical repair.
Isolated injury to the radial artery does not require repair and the
vessel could be safely ligated. The blood supply to the hand will be
maintained by the ulnar artery via the palmar arch.
III. THORACIC.
1. AORTA.
Injury of the aorta due to deep stab wound are usually fatal. Sometimes
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patients may reach the hospital alive and immediate thoracotomy to
arrest life-threatening haemorrhage may be life- saving. Traumatic
rupture of the aortic arch could result as a complication of head-on
collisions.
2. HEART.
Injuries to the heart are either penetrating, from knife wound or gunshot
or blunt trauma following high-speed motor vehicle accidents.
A. Penetrating trauma.
This could be found after an injury over the cardiac outline, mediastinum
or the epigastrium with possible pericardial laceration and haemorrhage
in the pericardial cavity causing cardiac tamponade.
Such a trauma patient with cardiac tamponade could present with the
classical signs of distended neck veins, faint heart sounds and low
blood pressure. Resuscitation measurements are rapidly made including
airway control and infusions with central venous cannulation.
In the severely and seriously compromised case,pericardiocentesis
may aid diagnosis and alleviate tamponade to allow time to prepare
for thoracotomy.
More severely risk patient should undergo immediate thoracotomy
through the 5th intercostal space.
If the diagnosis of cardiac tamponade is uncertain in un unstable patient,
or when laparotomy is required, a suxiphoid approach allows a window
to be cut in the pericardium. This may be done to check for the
presence of suspected tamponade, before proceeding to thoracotomy.
Gunshot injury is more likely to be associated with severe haemorrhage
and carry unfortunately poorer prognosis than knife wounds.
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B. Blunt trauma.
Road traffic accidents could cause compression of the heart as a result
of ribcage impacts against the steering wheel or safety belt that may
lead to cardiac contusion and rupture. Urgent resuscitative steps are
rapidly needed like, immediate surgery for the moribund case and
supportive therapy for cases with contusions.
All patients with cardiac trauma should be followed up. They must be
monitored with echocardiography and ECGs for the presence of
unsuspected septal or valvular injury.
IV. ABDOMINAL TRAUMA.
Massive serious intra-abdominal bleeding could occur from trauma to
the aorta or vena cava. They present an absolute surgical emergency
with unpredictable outcome. Such cases are shocked with a grossly
distended abdomen following stabbing or gunshot injury and urgent
laparotomy is rapidly required. And massive transfusions of compatible
blood must be available. A long midline incision is made and clot
evacuated to allow a rough assessment of the major source of bleeding.
As far as possible bleeding should be controlled by packs. Sometimes
thoracotomy through 7th intercostal space is needed to achieve better
assessment and possible clamping of the ruptured vessel. If the aortic
defect is readily visualized, passing balloon catheters proximally and
distally could help controlling the bleeding until adequate and proper
mobilization is achieved. The aortic defect is directly sutured or a
Dacron or PTFE patch is inserted. Major venous haemorrhage is often
more difficult to control than arterial haemorrhage. It is sometimes
necessary to mobilize the duodenum and the iliac vessels in the pelvis
to obtain adequate proximal and distal control.
Even here balloon catheters may provide the best way of controlling
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the haemorrhage. Vein patching of the caval defect is required. Other
intra-abdominal haemorrhage may occur from trauma to renal or
mesenteric vessels.
Direct penetrating injury could harm the renal vessels and blunt
injury may cause intimal tearing and thrombosis. The patient could
present with haematuria and should have an intravenous urogram in
the emergency room. This would indicate the presence of functioning
renal tissue on the side of injury and the presence or absence of a
contralateral kidney. The absence of function on one side is an
indication for renal angiography.
Arterial injury could be repaired, but are often best left if the patient
is stable. Then exploration could complicate the condition and may
end with avoidable nephrectomy.
Distal mesenteric vessel injury adjacent to the intestine is best dealt
with by ligation and excision of bowel segment as required.
Careful follow up and monitoring of renal function and blood Pressure
and bowel functions is an essential part of long-term care of such trauma
patients.
V. LOWER LIMB.
The assessment of arterial circulation of injured lower limbs is very
important and vital for the patient. In shock conditions and also in
elderly patients, pulses could be difficult to feel. A Doppler should be
used to detect the arterial circulation including the measurement of the
ankle: brachial index (ABPI). The index should normally be 1.0 or
greater. If the index is 0.9 or lower, a suspicion of proximal arterial
injury should be considered and arteriography is now advised. Frequent
reassessment with Doppler is quite helpful, especially in cases with
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equivocal findings and as a part of postoperative care after arterial
reconstruction. A deterioration in the Doppler signal quality or ABPI
is an indication for further arteriography or exploration.
1. Common femoral artery.
An injury to the common femoral artery could occur after laceration of
the groin or in crush injuries. The diagnosis is mostly readily apparent
and angiography to define the lesion is usually not needed.
Adequate exploration in the iliac fossa to achieve proper exposure of
the injury to detect the external iliac artery and vein and to control
distally to the common femoral artery. A vein patch is usually required
for the reconstruction of the femoral artery.
2. The superficial femoral artery.
Damage of the superficial femoral artery could be found after severe
comminuted fracture of the femur shaft or blast trauma with extensive
local damage or high speed road traffic accident.
The combination of an open laceration wound with unstable fracture
and ischemia is a complex problem.
The immediate priority is to achieve revascularization of the limb by
performing on-table angiography and exploring the wound to detect
the injured vessels at the site of occlusion.
The femoral vessels should be exposed in the groin and the common
femoral artery mobilized.
Usually the revascularization of the limb should take place before
orthopedic maneuvers to stabilize the fracture. In shock condition or if
the patient is hypotensive, pulses may be impalpable. Therefore it is
vitally important to check that the arterial run-off is adequate. And in
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trauma cases, on-table angiography on completion of the revascularization
procedure is mandatory.
3. Popliteal artery.
Injury of the popliteal artery is found after fracture dislocation of the
knee resulting from high speed motor vehicle accidents or also after
gun and blast injuries sometimes. The arterial injury is often a contusion
with intimal dissection and localized thrombosis.
In such cases immediate angiography should be done to define the
Level of injury. The treatment could include local vein patching of the
damaged artery or a short vein graft. The arterial run-off must be
checked by angiography and control of foot pulses.
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